Testing before noncardiac surgery

A different question with its own criteria

Testing before surgery asks a narrower question than testing for chest pain: not “does this patient have coronary disease?” but “is imaging needed to guide the care of this patient around this operation?” The goal is to prevent cardiovascular events in the perioperative period Doherty et al., 2024, Conclusions, and the 2024 appropriate use criteria (AUC) for multimodality imaging before noncardiac surgery were written for that purpose. They apply to nonurgent, nonemergent surgery, meaning surgery that is not required within 72 hours Doherty et al., 2024, General Assumptions, item 1. Imaging in this setting is used to stratify risk, and sometimes to modify the operative plan Doherty et al., 2024, Abstract. The document also notes that whether imaging is needed at all in many scenarios is not universally recognized Doherty et al., 2024, Abstract.

This lesson describes the logic as the document presents it, and nothing more. For a specific patient, the scenario builder holds the full tables.

The four things the tables ask

The AUC organizes its scenarios around a short series of questions Doherty et al., 2024, Introduction:

1. Is there known or suspected heart disease? That means ischemic heart disease, valve disease or heart failure, as opposed to no known or suspected heart disease.
2. Has there been imaging in the last 90 to 220 days? This window is meant to cover an initial test and any follow-up testing done to clarify a diagnosis. It is deliberately short, so that it is not confused with periodic surveillance. In most cases, repeating the same modality is not indicated Doherty et al., 2024, Introduction.
3. Are there new or worsening symptoms, or functional capacity below 4 METs? Patients who cannot exert themselves for noncardiac reasons are counted as “at risk” at less than 4 METs Doherty et al., 2024, Definitions, item 3. In its discussion of heart failure severity, the document describes people who can comfortably do moderate-intensity activity (for example, 4 to 7 METs) as generally not frail and having reasonable functional capacity Doherty et al., 2024, Definitions, item 19 (HF Severity Classification).
4. How risky is the operation? Procedures are assigned to low, intermediate and high risk, and to vascular or nonvascular groups. Solid organ transplantation is handled separately Doherty et al., 2024, Table A.

These choices lead to six tables in three sections: no heart disease and no recent testing (Tables 1.1 and 1.2), known or suspected heart disease and no recent testing (Tables 2.1 and 2.2), and heart disease with recent testing (Tables 3.1 and 3.2). In Section 1, the two tables split patients without symptoms by functional capacity. In Sections 2 and 3, the first table covers no new or worsening symptoms with functional capacity of 4 METs or more, and the second covers new or worsening symptoms or less than 4 METs Doherty et al., 2024, Introduction.

When imaging is considered at all

The authors describe an assumed gradient of risk based on whether heart disease is present, on diminished functional capacity and on how complex the procedure is Doherty et al., 2024, Discussion. Their results follow it. In scenarios with minimal risk from patient or procedural factors, the criteria usually point to no imaging beyond a careful history and physical and, in most cases, an ECG. In their results, imaging for low-risk procedures was rarely done, and as the patient’s illness, the complexity and the procedural risk rose, so did the level of appropriateness of preoperative imaging Doherty et al., 2024, Discussion Doherty et al., 2024, Conclusions. The authors identify ruling out ischemic heart disease as the single biggest driver toward imaging Doherty et al., 2024, Discussion.

The tool lets you see this directly. The three examples below share the same type of operation and change one step at a time: first, a patient with no known heart disease and good functional capacity; then the same operation with functional capacity below 4 METs; then a patient with known or suspected ischemic heart disease and new or worsening symptoms or low functional capacity.

Testing that would not add much

The document does not use the phrase “would not change management,” but its message points the same way. It states a goal of avoiding over-use of imaging before surgery where its value may be limited Doherty et al., 2024, Introduction. It also notes that the value of preoperative imaging has not been consistently shown to influence outcomes across populations, especially in lower-risk patients, and that practice varies widely Doherty et al., 2024, Conclusions. At the same time, it points out that failure to diagnose and treat cardiac comorbidities can lead to poor clinical outcomes Doherty et al., 2024, Conclusions.

Open the scenario builder →, choose “Before nonemergent noncardiac surgery,” and enter the surgical risk class, heart disease status, symptoms and functional capacity to see the criteria and the reasons for a specific patient.