Rapid Review·Cardiovascular
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HY Approach
T1Must knowApproach to Preoperative Cardiac Evaluation
Focus on
Five questions in order: is the surgery emergent, is there an active cardiac condition, what is the calculated risk, can the patient climb two flights of stairs, and would a stress test change anything? Most patients need no test at all. Continue the beta blocker, continue the statin, stop the SGLT2 inhibitor, and never revascularize a stable patient just to "clear" them.
Key takeaways
The goal
Change management, not reassure
find the patients whose cardiac risk should change the timing, monitoring or conduct of non-cardiac surgery.The five steps
Emergency surgery
life- or limb-saving surgery (ruptured aneurysm, perforated viscus, ischemic limb) proceeds with stabilization and monitoring; no elective cardiac testing.Active unstable cardiac conditions
acute coronary syndrome or unstable angina, decompensated heart failure, a significant uncontrolled arrhythmia, severe symptomatic valve disease (especially aortic stenosis), a recent infarction (under 60 days) or a recent stent.- Postpone elective surgery and treat first; a stress test adds nothing, because the diagnosis is known.
Estimate the risk (patient plus procedure)
the Revised Cardiac Risk Index (RCRI), one point each.- High-risk surgery (intraperitoneal, intrathoracic, suprainguinal vascular), ischemic heart disease, heart failure, cerebrovascular disease, insulin-treated diabetes, creatinine over 2 mg/dL.
- 0 to 1 point is low risk (under 1 percent): proceed without further testing. 2 or more points is elevated risk: go to step 4.
- Low-risk procedures (cataract, endoscopy, superficial, breast, ambulatory) proceed regardless of patient factors.
Functional capacity
4 metabolic equivalents or more without symptoms (two flights of stairs, a brisk walk, heavy housework) means proceed, no stress test.- Poor or unknown capacity alone does not mandate testing.
Test only if the result changes management
elevated risk plus poor or unknown capacity gets pharmacologic or exercise stress imaging only if a positive result would change the plan (cancel or modify the operation, revascularize for its own indications, intensify monitoring; Approach to Stress Testing).- Natriuretic peptide or troponin can refine risk.
Revascularization before surgery follows the usual indications
left main, three-vessel, acute coronary syndrome.- Prophylactic stenting or bypass to "get through" surgery does not reduce events, and a fresh stent delays surgery for months.
- The whole sequence is the Preoperative cardiac evaluation pathway.
| Patient | Next step |
|---|---|
| Asymptomatic, cataract or other low-risk surgery, any age | Proceed; no electrocardiogram, echo or stress test |
| Stable coronary disease, climbs two flights of stairs without symptoms, hernia repair | Proceed; continue medications; no stress test |
| Poor functional capacity but RCRI 0 to 1 | Proceed; no routine testing |
| RCRI 2 or more, cannot climb stairs, planned aortic surgery, result would alter care | Pharmacologic stress imaging |
| New or worsening exertional angina, or decompensated heart failure | Postpone elective surgery; evaluate and treat first |
| Severe symptomatic aortic stenosis before elective hip replacement | Valve team first, then surgery (Approach to Perioperative Cardiac Management) |
| Drug-eluting stent 3 months ago, elective surgery | Delay to 6 months (12 after an acute coronary syndrome) if possible; continue aspirin (Acute Coronary Syndrome) |
| Pacemaker or defibrillator | Interrogate within 6 to 12 months; magnet or reprogram for cautery |
Medications around surgery
Beta blockers
continue if already taking one (withdrawal causes rebound ischemia and arrhythmia).Statins
continue, and start before vascular surgery.Angiotensin-converting-enzyme inhibitors or receptor blockers
may hold the morning of surgery to avoid intraoperative hypotension.Aspirin
continue with stents or a recent acute coronary syndrome unless bleeding risk is prohibitive (neurosurgery).P2Y12 inhibitors
hold 5 days (clopidogrel, ticagrelor) or 7 (prasugrel); never both antiplatelets after a recent stent.Sodium-glucose cotransporter-2 inhibitors
hold 3 to 4 days (euglycemic ketoacidosis).Other diabetes drugs
hold the weekly glucagon-like peptide-1 agonist dose (aspiration); metformin the day of surgery if contrast or renal risk.Anticoagulants
by drug and risk (Approach to Perioperative Cardiac Management).Tests before and after
Preoperative electrocardiogram
for known coronary, arrhythmic, peripheral or cerebrovascular disease, structural heart disease, or elevated-risk surgery; not for asymptomatic low-risk procedures.Preoperative echocardiography
for new or worsening dyspnea, heart failure without a study in the past year, or a murmur suggesting significant valve disease without a recent echo.Postoperative surveillance
in elevated-risk patients, electrocardiogram and troponin for 48 to 72 hours.- A postoperative infarction is often silent (analgesia), presenting as hypotension, arrhythmia, dyspnea or delirium, and a rising troponin predicts mortality.
A 66-year-old with stable coronary disease and insulin-treated diabetes (RCRI 2) needs an elective hernia repair; he climbs two flights of stairs without symptoms. Does he need a stress test, and what happens to his metoprolol?
No stress test: 4 or more metabolic equivalents without symptoms means proceed. Continue the metoprolol (withdrawal causes rebound ischemia); never start a high-dose beta blocker on the day of surgery.
How it's tested
An 80-year-old with hypertension and a remote MI, asymptomatic, walks a mile daily, scheduled for cataract surgery: proceed — low-risk surgery, good functional capacity, no testing.
A 68-year-old diabetic on insulin with a creatinine of 2.3 and prior stroke (RCRI 3), unable to climb stairs because of arthritis, scheduled for open AAA repair: pharmacologic stress imaging is reasonable — the result could alter the plan (e.g., endovascular approach, revascularization for its own indication, ICU monitoring).
Stress test shows a small reversible defect; the patient has no angina and no left main or three-vessel disease: proceed to surgery on medical therapy — no prophylactic PCI.
Patient on metoprolol for years, surgery tomorrow: continue it — do not stop, do not double it.
Patient on empagliflozin, elective colectomy in a week: hold it 3–4 days before surgery.
New exertional chest pain in the pre-op clinic: unstable angina — cancel the elective operation and evaluate.
Go deeper
Guidelines: 2024 AHA/ACC Perioperative Cardiovascular Management Guideline
Related Step 2 pages: Approach to Perioperative Cardiac Management, Approach to Stress Testing, Acute Coronary Syndrome, Prosthetic Heart Valves, Heart Failure, Coronary Artery Bypass Grafting
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