Preoperative cardiac risk for noncardiac surgery

Perioperative cardiac assessment is stepwise. Emergency surgery proceeds with medical optimization as time allows. Postpone elective surgery for an active cardiac condition (acute coronary syndrome, decompensated heart failure, unstable arrhythmia). Otherwise estimate the risk of a major adverse cardiac event with a validated tool such as the Revised Cardiac Risk Index or an NSQIP calculator; low-risk patients and low-risk surgery proceed without further cardiac testing.

Assess functional capacity with a structured tool such as the Duke Activity Status Index rather than an eyeball estimate; roughly 4 METs, or climbing two flights of stairs, suggests adequate capacity. Order stress testing only when the result would change management, meaning elevated-risk surgery with poor or unknown capacity and elevated calculated risk. Routine preoperative stress testing and routine resting echocardiography are not recommended in low-risk, stable, or good-capacity patients; get a resting echo for new dyspnea, signs of heart failure, or suspected new ventricular dysfunction.

In higher-risk patients (known cardiovascular disease, or age 65 and older, or 45 and older with cardiovascular symptoms) going for elevated-risk surgery, it is reasonable to check BNP or NT-proBNP before surgery to refine risk, and troponin can supplement it. Postoperative troponin at 24 and 48 hours can detect silent myocardial injury in these patients, a change from the older signs-and-symptoms-only approach.

Continue beta-blockers if the patient is already on them, but do not start a beta-blocker on the day of surgery, which increases mortality. Continue statins, and start one perioperatively if otherwise indicated. Consider holding an ACE inhibitor or ARB about 24 hours before elevated-risk surgery to limit intraoperative hypotension, and continue it in heart failure. Stop SGLT2 inhibitors 3 to 4 days before surgery to avoid euglycemic ketoacidosis. For GLP-1 receptor agonists the guideline flags aspiration risk but defers the timing to anesthesiology and multisociety guidance rather than issuing its own rule. Coordinate antiplatelet and anticoagulant timing, and the interval after coronary stenting, with cardiology; routine heparin bridging is not recommended for most patients.