Preoperative cardiac evaluation

1 · Urgency. Emergency surgery goes ahead with no testing step. Urgent surgery leaves hours, so testing is limited to what changes management in that window. CCTA is contraindicated in urgent or emergency surgery.

2 · Active cardiac conditions. ACS, decompensated HF, significant arrhythmia, symptomatic severe AS and severe MS are treated first. These are also the unstable states in which stress testing is avoided. ACS before elective surgery calls for revascularization as appropriate and deferral of surgery (COR 1). Severe AS calls for evaluation for valve intervention before elective surgery (COR 1, C-LD), and severe MS the same (COR 1, B-NR).

3 · Recent PCI. Elective surgery that stops an antiplatelet agent within 30 days of a BMS or DES is potentially harmful (COR 3: Harm). After a DES, the ideal delays are 12 months or more for ACS (COR 1) and 6 months or more for chronic coronary disease (COR 2a). Time-sensitive surgery may be considered 3 months or more after a DES (COR 2b). Wait at least 14 days after balloon angioplasty (COR 1). Inside a window this page says defer, or decide with cardiology. It never says proceed.

4 · Risk modifiers. These are severe valve disease, pulmonary hypertension, congenital heart disease, prior PCI or CABG, recent stroke, an implanted cardiac device, and frailty. This page adds a medically managed MI within 60 days, HCM, LVAD, heart transplant, and recent TAVI or TEER. A recent MI without revascularization defers planned surgery for cardiology review. They add risk that most calculators miss, so they route to a team discussion on timing and testing. The list comes from summaries (CCJM 2025, JCVA 2025). One exception: with asymptomatic moderate or severe AS and normal LV function on echo within a year, proceeding with elective low-risk surgery is reasonable (COR 2a, C-LD).

5 · Risk. Elevated risk means a predicted MACE risk above 1% (the Figure 1 footnote's threshold; Table 2 words it as 1% or more), and an RCRI above 1 counts as elevated. A validated risk tool is reasonable (COR 2a). The ACS NSQIP calculators and AUB-HAS2 are also listed in the guideline, which prefers none of them. This page computes only the RCRI.

6 · Functional capacity. Poor capacity means under 4 METs or a DASI of 34 or less. A DASI of 34 or less here overrides a self-reported “4 METs or more”.

7 · Biomarkers. Abnormal means BNP above 92 ng/L, NT-proBNP 300 ng/L or more, or troponin above the 99th percentile. BNP or NT-proBNP is COR 2a and troponin COR 2b, in known CVD, age 65 or older, or age 45 or older with symptoms, before elevated-risk surgery. They are not solicited outside the poor-capacity branch. If one is entered there and is abnormal, it needs explaining before elective surgery.

8 · Testing. Stress testing or CCTA may be considered with elevated risk and poor or unknown capacity, only if the result would change management (COR 2b). Neither is recommended routinely (COR 3: No Benefit).

The guideline's algorithm has not been prospectively validated and does not replace clinical judgment.

One point each, for a total of 0–6: high-risk surgery, ischemic heart disease, heart failure, cerebrovascular disease, preoperative insulin, and creatinine of 2.0 mg/dL or above. Lee 1999 defined the creatinine item as above 2.0 mg/dL, while the guideline's Table 4 prints “≥2.0”. This page counts exactly 2.0 as a point, which errs to the safe side.

The outcome was major cardiac complications. The cohort was patients aged 50 or older having elective major noncardiac surgery in one hospital in the 1990s. Discrimination is modest in pooled validation and worse in vascular surgery.

Beta-blockers: continue if already on one (COR 1). Never start on the day of surgery (COR 3: Harm, B-R). For a new indication, start well in advance, optimally more than 7 days before (COR 2b).

Statins: continue (COR 1). Start in statin-naïve patients who meet criteria, with long-term intent (COR 1, B-R).

SGLT2 inhibitors: withhold for 3 to 4 days before surgery when feasible (COR 1, C-LD). US labels say to withhold for at least 3 days “if possible”, at least 4 for ertugliflozin, and for sotagliflozin at least 3 days before major surgery. Labels also say to consider ketone monitoring in patients at risk of ketoacidosis, and to resume once clinically stable and eating.

RAAS inhibitors: on them for HTN with controlled BP before elevated-risk surgery, omitting 24 h before may limit hypotension (COR 2b, B-R). On them for HFrEF, continuation is reasonable (COR 2a, C-EO). In most patients with HTN, continuing antihypertensive therapy is reasonable (COR 2a, C-EO).

GLP-1 receptor agonists: the ACC/AHA guideline has no graded recommendation. The 2024 multi-society guidance (ASA, AGA, ASMBS, ISPCOP, SAGES) says therapy “may be continued pre-operatively in patients without elevated-risk of delayed gastric emptying and aspiration”. Higher-risk features are the escalation phase, a higher dose, weekly dosing, GI symptoms, and other causes of slow gastric emptying. If a hold is chosen, it suggests the day of surgery for daily formulations and a week before for weekly ones. Other options are a liquid diet for at least 24 h and rapid sequence induction. A 2025 SPAQI consensus (Br J Anaesth) also covers this and is cited without its recommendations, which could not be verified here.

Anticoagulants: plan interruption with a multidisciplinary, time-based approach (COR 1, B-NR). Routine bridging is not recommended (COR 3: Harm, C-LD). For VKA interruption with high thrombotic risk, heparin bridging can be effective (COR 2a, C-LD). See the peri-procedural anticoagulation tool.

Surgical risk: ESC grades the procedure alone as low (under 1%), intermediate (1–5%) or high (over 5%) 30-day risk of CV death, MI or stroke. ACC/AHA uses a combined patient-and-surgery threshold of 1%.

Biomarkers: before intermediate- or high-risk surgery in patients with CVD, risk factors or age 65 or older, ESC gives hs-troponin Class I and BNP/NT-proBNP Class IIa. ACC/AHA gives BNP/NT-proBNP 2a and troponin 2b. ESC defines perioperative myocardial injury as an hs-troponin rise above the URL on day 1 or 2.

Functional capacity: ESC uses DASI or the ability to climb two flights of stairs, and notes that interview-based METs have not shown proven value.

ECG: ESC recommends it at age 65 or older, or with known CVD, before intermediate- or high-risk surgery. ESC advises against it routinely in low-risk patients having low-risk surgery.

Recommendations and their classes follow the ACC/AHA guideline (doi:10.1161/CIR.0000000000001472, reaffirming doi:10.1161/CIR.0000000000001285). They were checked during the October 2026 build against the AHA/ACC recommendation slide set and the publisher HTML of the guideline. The Figure 1 footnotes (BNP above 92 ng/L, NT-proBNP 300 ng/L or more) and Tables 2 and 4 come from that HTML.

Lines that rest on summaries say so on the page and carry “LOE not re-verified” or “No COR”:

• the Figure 1 step order and risk-modifier list;
• CIED interrogation intervals, heart transplant, and AF rate control (JCVA 2025 highlights, PMC12904102);
• stopping primary-prevention aspirin and the BP delay (Cohn, CCJM 2025);
• the 60-day post-MI threshold, from the superseded 2014 guideline and not re-verified;
• GLP-1 RA management (multi-society guidance, Oct 2024).