Pre-op risk
How the 2026 AHA/ACC guideline for perioperative cardiovascular management approaches risk before noncardiac surgery, taught step by step. The 2026 edition reaffirms the 2024 guideline with no changes .
COR is the Class of Recommendation, the guideline’s strength of a recommendation; LOE is its Level of Evidence.
Risk scores side by side
Table 4 of the guideline lists seven risk scores, shown here in its order. Pick two or three to line up what goes in, what each predicts and what counts as elevated risk. The outcome each one predicts differs, so the columns describe the scores; they do not rank them .
Comparing 2 of up to 3. Picking a fourth swaps out the one you picked first.
Goldman Index (1977)
- What goes in
Points for age over 70 (5), MI within 6 months (10), jugular venous distention or third heart sound (11), 5 or more PVCs per minute (7), nonsinus rhythm or PACs on the preoperative ECG (7), aortic stenosis (3), intraperitoneal, intrathoracic or aortic surgery (3) and any emergency surgery (4)
Classes: I 0 to 5 points, II 6 to 12, III 13 to 25, IV 26 or more
- Outcome predicted
- intraoperative or postoperative MI, pulmonary edema, VT and cardiac death
- What counts as elevated
Elevated risk is class II or higher (6 points or more)
- Derivation size
- 1001 patients
RCRI (1999)
- What goes in
1 point for each of 6 criteria
Classes: I = RCRI 0, II = 1, III = 2, IV = 3 or more
- Outcome predicted
- MI, pulmonary edema, ventricular fibrillation, complete heart block and cardiac death
- What counts as elevated
Elevated risk is an RCRI above 1
- Derivation size
- 1422 patients
What the guideline says about choosing between them
No index is preferred
Many indices exist (for example RCRI, the NSQIP MICA calculator and the universal NSQIP surgical risk calculator), but the guideline finds no data to favor one over another, and predicted risk varies a lot between tools.
They disagree about who is low risk
In a pooled analysis of 24 validation studies the RCRI discriminated cardiac events only modestly, and the tools disagree on who is low risk (estimated MACE below 1%).
Poorer discrimination in vascular surgery
Few studies have changed perioperative treatment based on a risk score, and scores discriminate less well in vascular surgery, probably because MI risk is underestimated.
What “elevated risk” means in the guideline
Low risk: combined surgical and patient characteristics predict a MACE risk below 1%.
Elevated risk: combined surgical and patient characteristics predict a MACE risk of 1% or more. This category includes intermediate and high surgical risk.
Whether calculated risk counts as elevated depends on the calculator used. Traditionally an RCRI above 1, or a calculated MACE risk above 1% on any perioperative risk calculator, marks elevated risk.
Abbreviations on this section
- MACE
- major adverse cardiovascular events
- MI
- myocardial infarction (heart attack)
- NSQIP
- National Surgical Quality Improvement Program
- MICA
- myocardial infarction or cardiac arrest
- ASA class
- American Society of Anesthesiologists physical status class
- RCRI
- Revised Cardiac Risk Index
- VT
- ventricular tachycardia
- PVC / PAC
- premature ventricular / atrial contraction
- HF
- heart failure
- CPT
- Current Procedural Terminology (procedure codes)