Preoperative Testing for Low-Risk Surgery
For asymptomatic patients undergoing low-risk surgical procedures, routine preoperative ECGs, laboratory tests, chest X-rays, and cardiac stress testing are not indicated and should not be performed. 1
What Defines Low-Risk Surgery
Low-risk procedures carry less than 1% risk of major adverse cardiac events (MACE) and include:
- Superficial procedures (skin biopsies, minor dermatologic surgery) 1
- Cataract surgery 1
- Carpal tunnel release 2
- Endoscopic procedures 1
- Breast surgery 1
Recommended Preoperative Evaluation
History and Physical Examination Only
For healthy, asymptomatic patients undergoing low-risk surgery, the preoperative evaluation should consist of:
- Focused history assessing for active cardiac conditions (unstable angina, recent MI, decompensated heart failure, significant arrhythmias, severe valvular disease) 3
- Functional capacity assessment - specifically asking if the patient can climb 2 flights of stairs or perform activities requiring ≥4 METs without symptoms 4
- Medication review to ensure continuation of chronic medications (beta-blockers, statins) 4
- Bleeding history to identify potential coagulation disorders 1
No Routine Testing Required
The following tests are explicitly not recommended for asymptomatic patients undergoing low-risk surgery:
12-Lead ECG: Class III (No Benefit) recommendation - routine preoperative ECG is not useful for asymptomatic patients undergoing low-risk procedures 1
Cardiac stress testing: Class III (No Benefit) - routine screening with noninvasive stress testing is not useful for low-risk noncardiac surgery 1
Left ventricular function assessment: Class III (No Benefit) - routine preoperative evaluation of LV function is not recommended 1
Laboratory tests: Not routinely indicated unless specific clinical concerns arise from history 1
Chest X-ray: Not recommended for routine preoperative screening in low-risk surgery 1
When Testing May Be Considered
Testing should only be performed if it will change perioperative management 1. Consider selective testing only if:
- Active cardiac symptoms are present (chest pain, dyspnea, palpitations) requiring evaluation independent of surgery 3
- Known cardiovascular disease with change in clinical status 1
- Specific medication concerns (e.g., electrolytes for patients on digoxin or diuretics) 1
- Abnormal bleeding history suggesting coagulation disorder 1
Special Population: Cataract Surgery
For patients undergoing cataract surgery specifically, a large randomized controlled trial of over 19,000 patients demonstrated no difference in outcomes between those who received preoperative testing versus no testing 1. Patients in their usual state of health undergoing cataract surgery do not require any preoperative testing. 1
Common Pitfalls to Avoid
Do not order tests "just to have them" - The ACC/AHA explicitly states that no test should be performed unless it is likely to influence patient treatment 1
Do not confuse ASA classification with testing requirements - ASA classification is based on systemic disease burden, not age, and does not automatically trigger testing requirements 5
Do not delay surgery for unnecessary testing - Routine preoperative testing for low-risk procedures can lead to unnecessary surgery delays without improving outcomes 2, 6
Avoid institutional protocols that conflict with evidence - Many facilities continue routine testing despite guidelines recommending against it due to unclear responsibility for test ordering and concerns about litigation 6
Implementation Strategy
To successfully reduce unnecessary preoperative testing:
- Establish clear institutional guidelines specifying who is responsible for test ordering 6
- Pre-screen patients to determine if preoperative clinic evaluation is even necessary for truly low-risk cases 2
- Build consensus among stakeholders (surgeons, anesthesiologists, preoperative clinic staff) using evidence-based education 2
- Create dedicated pathways for low-risk procedures that bypass routine testing protocols 2