What is the recommended approach for pre-surgical cardiac assessment in patients undergoing non-emergency surgery?

Pre-Surgical Cardiac Assessment

Use a stepwise algorithmic approach based on surgery urgency, active cardiac conditions, surgical risk, and functional capacity—proceeding directly to surgery for low-risk patients without further testing, while reserving cardiac evaluation for those with active unstable conditions or high-risk scenarios. 1

Step 1: Determine Surgery Urgency

• Emergency surgery: Proceed immediately with appropriate monitoring and management based on clinical assessment, identifying cardiac risk factors that may influence perioperative care but without delaying the procedure 1
• Urgent or elective surgery: Continue to systematic evaluation 1

Step 2: Screen for Active Cardiac Conditions

Identify patients requiring immediate evaluation and treatment before proceeding:

• Unstable coronary syndromes (myocardial infarction within 30 days, unstable angina) 1
• Decompensated heart failure 1, 2
• Significant arrhythmias (high-grade AV block, symptomatic ventricular arrhythmias, supraventricular arrhythmias with uncontrolled ventricular rate) 1, 2
• Severe valvular disease (severe aortic stenosis, symptomatic mitral stenosis) 1, 2

If any active condition is present: Refer for cardiology evaluation and management according to disease-specific guidelines before surgery 1, 2

Step 3: Assess Surgical Risk

Classify the planned procedure by 30-day risk of myocardial infarction or cardiac death:

• Low-risk (<1%): Endoscopy, superficial procedures, cataract surgery, breast surgery 1, 2
• Intermediate-risk (1-5%): Intraperitoneal/intrathoracic procedures, carotid endarterectomy, head and neck surgery 1, 2
• High-risk (>5%): Aortic and major vascular surgery, peripheral vascular surgery, prolonged procedures with large fluid shifts 1, 2

For low-risk surgery: Proceed without further cardiac testing regardless of clinical risk factors, as perioperative cardiac risk is <1% 1

Step 4: Evaluate Functional Capacity

For intermediate- or high-risk surgery, assess metabolic equivalent tasks (METs):

• Good functional capacity (≥4 METs): Ability to climb 2 flights of stairs or walk 4 blocks without symptoms 1
• Poor functional capacity (<4 METs): Unable to perform above activities 1

Use the Duke Activity Status Index for objective measurement 1

If functional capacity ≥4 METs: Proceed to surgery without further cardiac testing, even with clinical risk factors present 1

Step 5: Identify Clinical Risk Factors (Revised Cardiac Risk Index)

For patients with poor or unknown functional capacity, count the following:

• History of ischemic heart disease 1
• History of compensated heart failure 1
• History of cerebrovascular disease 1
• Diabetes mellitus requiring insulin 1
• Renal insufficiency (creatinine >2 mg/dL) 1
• High-risk surgery 1

Step 6: Determine Need for Additional Testing

For intermediate-risk surgery with poor functional capacity:

• 1-2 clinical risk factors: Proceed to surgery with baseline ECG and optimized medical management 1
• ≥3 clinical risk factors: Consider non-invasive stress testing if results will change management 1

For high-risk surgery with poor functional capacity:

• ≥2 clinical risk factors: Consider non-invasive stress testing 1

Recommended Pre-Operative Testing

All Patients

• Vital signs and cardiac physical examination within 2 hours of surgery (blood pressure, heart rate) 1

Intermediate- and High-Risk Patients

• Baseline ECG for patients with known cardiovascular disease, peripheral arterial disease, cerebrovascular disease, or structural heart disease 1
• Full blood count and renal function 1
• Coagulation profile (prothrombin time, platelet count) 1

High-Risk Patients Undergoing High-Risk Surgery

• Troponin pre-operatively and at 24 and 48 hours post-operatively to detect subclinical cardiac injury 1
• Echocardiography for patients with suspected or known heart failure with ongoing symptoms 1
• BNP/NT-proBNP for additional risk stratification in patients with suspected heart failure 1

Patients ≥70 Years

• Frailty assessment using a validated tool 1

Perioperative Medical Optimization

Beta-Blockers

• Consider initiation in patients with known ischemic heart disease or myocardial ischemia 1
• Start 30 days to minimum 2 days before surgery with low-dose titration 1
• Target: Resting heart rate 60-70 bpm with systolic blood pressure >100 mmHg 1
• Continue post-operatively 1

ACE Inhibitors/ARBs

• Consider before surgery in patients with heart failure and systolic LV dysfunction (LVEF <40%) 1
• Initiate at least 1 week before surgery 1

Statins

• Consider initiation in patients undergoing vascular surgery 1
• Ideally start 30 days before surgery 1

Antiplatelet Therapy

• Continue aspirin in patients with recent coronary stents (4 weeks after bare-metal stent, 3-12 months after drug-eluting stent) 1
• Discontinuation may be considered when hemostasis is difficult to control during surgery 1

Anticoagulation

• Continue peri-operatively for low-risk surgery 1

Common Pitfalls to Avoid

• Do not perform routine stress testing in asymptomatic patients with good functional capacity, as results rarely change management and delay surgery unnecessarily 1
• Do not pursue coronary revascularization solely to reduce perioperative risk in stable coronary disease, as it does not improve outcomes and adds procedural risk 1
• Do not order extensive testing for low-risk procedures, as the pre-test probability makes positive predictive value extremely low 1
• Avoid starting beta-blockers on the day of surgery or without proper titration, as this increases stroke and mortality risk 1

Interpretation of Stress Testing (When Performed)

• No ischemia or mild-to-moderate ischemia (1-2 vessel disease): Proceed to surgery 1
• Extensive stress-induced ischemia: Requires individualized perioperative management with multidisciplinary discussion weighing surgical benefit against cardiac risk 1