Pre-op risk

The strongest class on this board.

• Recommended (1)LOE B-NRSection 4.2.1

  In patients having noncardiac surgery who have new dyspnea, physical examination findings of heart failure, or suspected new or worsening ventricular dysfunction, a preoperative evaluation of LV function is recommended to guide perioperative management.

  Applies to

  • new dyspnea, heart failure findings, or suspected new or worsening ventricular dysfunction

  ›Why

  • Lower LVEF, higher surgical risk and more comorbid risk factors each raise perioperative MACE risk; grade 3 diastolic dysfunction carried a 70% higher MACE risk than grades 1 to 2. Thompson et al., 2026, Section 4.2.1, Synopsis
  • In a cohort of 570 patients, risk models with echocardiographic data outperformed clinical-only models (c statistic 0.73 versus 0.68), but the added value was seen only in higher-risk patients. Thompson et al., 2026, Section 4.2.1, Recommendation 1 supportive text
• Recommended (1)LOE B-NRSection 9.2

  Patients who develop STEMI after noncardiac surgery should be considered for guideline-directed medical therapy, including consideration of invasive coronary angiography, weighing bleeding and thrombotic risk against how severe the presentation is.

  Applies to

  • STEMI after noncardiac surgery

  ›Why

  • Perioperative STEMI from acute plaque rupture is a minority of perioperative MIs but carries in-hospital mortality of 30% to 35%; emergent ICA should be strongly considered. Thompson et al., 2026, Section 9.2, Recommendation 1 supportive text
  • Decisions should be team-based, involving the surgeon, anesthesiologist and cardiologist. Thompson et al., 2026, Section 9.2, Recommendation 1 supportive text
• Recommended (1)LOE C-EOSection 9.2

  Patients who develop NSTEMI after noncardiac surgery should receive the medical therapy recommended for spontaneous MI, after considering postoperative bleeding risk and hemodynamic status.

  Applies to

  • NSTEMI after noncardiac surgery

  ›Why

  • Therapy should include at least 1 antiplatelet if benefit outweighs bleeding risk, and a high-intensity statin. If hemodynamics allow, beta blockers, ACE inhibitors and nitrates may be considered for angina relief and long-term risk reduction. Thompson et al., 2026, Section 9.2, Recommendation 2 supportive text
  • In suspected type 2 MI, management should address the underlying supply-demand mismatch (for example hypertension, hypotension, tachycardia, anemia); troponin can also rise from heart failure, sepsis or pulmonary embolism. Thompson et al., 2026, Section 9.2, Synopsis

• Reasonable (2a)LOE B-NRSection 3.1

  In patients with known cardiovascular disease who are being considered for noncardiac surgery, a validated risk-prediction tool can be useful to estimate the risk of perioperative major adverse cardiovascular events (MACE).

  Applies to

  • known cardiovascular disease
  • being considered for noncardiac surgery

  ›Why

  • 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. Thompson et al., 2026, Section 3.1, Synopsis
  • 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. Thompson et al., 2026, Section 3.1, Synopsis
  • 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%). Thompson et al., 2026, Section 3.1, Recommendation 1 supportive text
• Reasonable (2a)LOE B-NRSection 3.2

  In patients having elevated-risk noncardiac surgery, a structured functional capacity assessment, such as the Duke Activity Status Index (DASI), is reasonable to stratify the risk of perioperative adverse cardiovascular events.

  Applies to

  • elevated-risk surgery

  ›Why

  • Functional capacity is usually expressed in METs, with 4 METs as the poor-capacity threshold; a common bedside screen is whether the patient can climb 2 flights of stairs, which the guideline associates with more than 4 METs. Thompson et al., 2026, Section 3.2, Synopsis
  • In most cases, functional and asymptomatic patients can proceed with planned surgery without further cardiovascular testing. Thompson et al., 2026, Section 3.2, Synopsis
  • In the METs study, the clinician's subjective impression of functional capacity was not associated with outcomes, whereas DASI was; DASI scores of 34 or less were linked to higher odds of 30-day death or MI. Thompson et al., 2026, Section 3.2, Recommendation 1 supportive text
  • Self-reported inability to walk 4 blocks or climb 2 flights of stairs was associated with in-hospital cardiovascular events in 9.6% versus 5.2% of patients. Thompson et al., 2026, Section 3.2, Recommendation 1 supportive text
• Reasonable (2a)LOE B-NRSection 3.3

  In all patients 65 years of age or older, and in patients younger than 64 with perceived frailty, who are having elevated-risk noncardiac surgery, a preoperative frailty assessment with a validated tool can be useful to evaluate perioperative risk and guide management.

  Applies to

  • elevated-risk surgery
  • age 65 or older, or younger than 64 with perceived frailty

  ›Why

  • Frailty is an independent risk factor for adverse outcomes after noncardiac surgery at any age. In a meta-analysis it was associated with a relative risk of 3.71 for 30-day mortality and 2.39 for 30-day complications. Thompson et al., 2026, Section 3.3, Synopsis and Recommendation 1 supportive text
  • Several validated screening tools exist (Table 6). Most comparisons were neutral; one prospective study found the Clinical Frailty Scale predicted outcomes better than the Fried phenotype and the Frailty Index. Thompson et al., 2026, Section 3.3, Recommendation 1 supportive text
  • For older patients with advanced frailty, poor function and short life expectancy, goals of care and shared decision-making belong in preoperative planning; prehabilitation may help selected frail patients. Thompson et al., 2026, Section 3.3, Recommendation 1 supportive text
• Reasonable (2a)LOE B-NRSection 3.4

  In patients with known cardiovascular disease, or age 65 or older, or age 45 or older with symptoms suggestive of cardiovascular disease, who are having elevated-risk noncardiac surgery, it is reasonable to measure BNP or NT-proBNP before surgery to supplement risk evaluation.

  Applies to

  • elevated-risk surgery
  • known CVD, or age 65 or older, or age 45 or older with symptoms suggestive of CVD

  ›Why

  • Both BNP and troponin have high prognostic value and excellent negative predictive value for perioperative cardiac complications, but no study has shown that acting on an elevated preoperative value improves outcomes, and their use in low-risk patients has not been evaluated. Thompson et al., 2026, Section 3.4, Synopsis
  • Optimal BNP and NT-proBNP thresholds for perioperative risk prediction are not clearly established. In one cohort of 3597 patients, adding NT-proBNP to risk scores combined with self-reported functional status did not significantly improve prediction. Thompson et al., 2026, Section 3.4, Recommendation 1 supportive text
• Reasonable (2a)LOE B-NRSection 4.1

  In patients with known coronary heart disease, significant arrhythmia, peripheral arterial disease, cerebrovascular disease, other significant structural heart disease, or symptoms of cardiovascular disease who are having elevated-risk surgery, a preoperative resting 12-lead ECG is reasonable to set a baseline and guide perioperative management.

  Applies to

  • elevated-risk surgery
  • known CHD, significant arrhythmia, PAD, cerebrovascular disease, other significant structural heart disease, or CVD symptoms

  Qualifier: Active symptoms and signs of cardiovascular disease here include chest pain, dyspnea, undiagnosed palpitations, tachycardia, syncope, or murmurs.

  ›Why

  • The resting ECG can carry prognostic information in coronary heart disease but rarely adds to what risk-assessment tools already show. Thompson et al., 2026, Section 4.1, Synopsis
  • Comparing with prior tracings helps when abnormalities are found, and the preoperative ECG serves as the baseline if a postoperative complication develops. Thompson et al., 2026, Section 4.1, Recommendation 1 supportive text
• Reasonable (2a)LOE B-NRSection 4.1

  In patients having noncardiac surgery whose preoperative ECG shows new abnormalities, further evaluation is reasonable to refine cardiovascular risk assessment.

  Applies to

  • new preoperative ECG abnormalities

  Qualifier: Abnormalities may include ST-segment elevation, ST depression, T-wave inversion, left ventricular hypertrophy, significant pathologic Q waves, Mobitz type II or higher atrioventricular block, bundle branch block, QT prolongation, or atrial fibrillation.

  ›Why

  • Which ECG abnormalities should prompt more information, consultation or testing is not well defined; the guideline lists notable ones (see the footnote). Most studies show little added prognostic value beyond clinical risk assessment. Thompson et al., 2026, Section 4.1, Recommendation 2 supportive text
  • An abnormal ECG often does not change management, except Mobitz type II or higher block, atrial fibrillation with rapid ventricular response or new-onset atrial fibrillation, or a prolonged QT interval. Incidental Q waves or bundle branch block in an asymptomatic patient should not by themselves lead to revascularization before surgery. Thompson et al., 2026, Section 4.1, Recommendation 3 supportive text
• Reasonable (2a)LOE C-LDSection 4.2.1

  In patients with known heart failure who have worsening dyspnea or another change in clinical status before noncardiac surgery, a preoperative assessment of LV function is reasonable to guide perioperative management.

  Applies to

  • known heart failure
  • worsening dyspnea or change in clinical status

  ›Why

  • Symptomatic patients with lower LVEF having higher-risk procedures are at highest risk. In one cohort, 90-day mortality was 5.49% with symptomatic heart failure, 4.9% with asymptomatic heart failure and 1.2% without heart failure. Thompson et al., 2026, Section 4.2.1, Recommendation 2 supportive text
  • Comprehensive transthoracic echocardiography remains the standard for assessing LV function; handheld focused cardiac ultrasound has been studied in small trials and is considered only when done by trained people. Thompson et al., 2026, Section 4.2.1, Recommendation 2 supportive text
• Reasonable (2a)LOE B-NRSection 9.1

  In patients who develop MINS, particularly those not previously known to carry excess cardiovascular risk, outpatient follow-up is reasonable to optimize cardiovascular risk factors.

  Applies to

  • MINS diagnosed
  • especially not previously known to have excess cardiovascular risk

  ›Why

  • Best management is uncertain but the prognostic impact is clear: elevated postoperative troponin consistently marks higher short- and long-term mortality. Patients should be told of the MINS diagnosis during the surgical stay. Thompson et al., 2026, Section 9.1, Recommendation 3 supportive text
  • Early cardiology consultation or transfer after MINS was linked to lower early mortality in observational studies. Aspirin and statin use in patients with perioperative MI was associated with lower 30-day mortality in a POISE post hoc analysis; this evidence is observational only. Thompson et al., 2026, Section 9.1, Recommendation 3 supportive text
• Reasonable (2a)LOE C-LDSection 9.2

  Patients who develop NSTEMI after noncardiac surgery can be considered for invasive coronary angiography, weighing bleeding and thrombotic risk against how severe the presentation is.

  Applies to

  • NSTEMI after noncardiac surgery

  ›Why

  • Retrospective data linked invasive management to lower in-hospital mortality, but the decision must weigh residual postoperative bleeding risk, type of surgery, time since surgery, peak troponin, ischemic ECG changes and other patient factors. Thompson et al., 2026, Section 9.2, Recommendation 3 supportive text
  • Patients with symptoms not responding to medical therapy, hemodynamic instability, persistent biomarker elevation, or new regional wall motion abnormalities or reduced ventricular function may gain most from urgent ICA; decide as a team with surgeon, anesthesiologist and cardiologist. Thompson et al., 2026, Section 9.2, Recommendation 3 supportive text

• May be considered (2b)LOE B-NRSection 3.4

  In patients with known cardiovascular disease, or age 65 or older, or age 45 or older with symptoms suggestive of cardiovascular disease, who are having elevated-risk noncardiac surgery, it may be reasonable to measure cardiac troponin before surgery to supplement risk evaluation.

  Applies to

  • elevated-risk surgery
  • known CVD, or age 65 or older, or age 45 or older with symptoms suggestive of CVD

  ›Why

  • High-sensitivity troponin in patients without signs or symptoms of ischemia can reveal chronic myocardial injury and higher risk, but no action rests on that finding alone. Thompson et al., 2026, Section 3.4, Recommendation 2 supportive text
  • A baseline value helps interpret postoperative troponin and confirm acute myocardial injury afterward; adding preoperative troponin improved the RCRI's prediction of perioperative MACE. Thompson et al., 2026, Section 3.4, Recommendation 2 supportive text
• May be considered (2b)LOE B-NRSection 4.1

  In asymptomatic patients having elevated-risk surgery who have no known cardiovascular disease, a preoperative resting 12-lead ECG may be considered to set a baseline and guide perioperative management.

  Applies to

  • elevated-risk surgery
  • asymptomatic
  • no known CVD

  ›Why

  • An important reason to record an ECG in asymptomatic patients having elevated-risk surgery is to have a baseline for comparison if a postoperative ECG is abnormal. Thompson et al., 2026, Section 4.1, Recommendation 3 supportive text
  • No standard age or risk-factor cutoff for a preoperative ECG has been defined, and the best interval between an ECG and elective surgery is unknown. Thompson et al., 2026, Section 4.1, Recommendation 2 supportive text
• May be considered (2b)LOE B-NRSection 4.3

  For patients having elevated-risk noncardiac surgery who have poor or unknown functional capacity and elevated perioperative cardiovascular risk by a validated risk tool, stress testing may be considered to look for inducible myocardial ischemia.

  Applies to

  • elevated-risk surgery
  • poor or unknown functional capacity
  • elevated risk by a validated risk tool

  Qualifier: Poor functional capacity is considered to be under 4 METs or a DASI score of 34 or less.

  ›Why

  • The goal of preoperative ischemia testing is not to find undiagnosed CAD but to identify patients in whom revascularization is believed to improve outcomes, specifically left main disease or severe multivessel disease with reduced LVEF. Thompson et al., 2026, Section 4.3, Synopsis
  • An abnormal test has only modest positive predictive value and may add little beyond standard risk tools or natriuretic peptides; it should not prompt angiography or revascularization unless it shows high-risk features. Thompson et al., 2026, Section 4.3, Synopsis
  • Testing can be considered in select patients if high-risk ischemia is suspected or there is an indication for testing independent of the planned surgery. Exercise testing is preferred to pharmacologic testing when the patient can exercise. Thompson et al., 2026, Section 4.3, Recommendation 1 supportive text
• May be considered (2b)LOE B-NRSection 4.5

  For patients having elevated-risk surgery who have poor or unknown functional capacity and elevated perioperative cardiovascular risk by a validated risk tool, CCTA to detect high-risk coronary anatomy may be considered.

  Applies to

  • elevated-risk surgery
  • poor or unknown functional capacity
  • elevated risk by a validated risk tool

  Qualifier: Poor functional capacity is considered to be under 4 METs or a DASI score of 34 or less.

  Qualifier: High-risk coronary anatomy means obstructive stenosis with left main stenosis of 50% or more, or anatomically significant 3-vessel disease (70% stenosis or more).

  ›Why

  • CCTA can be considered in select cases when high-risk anatomy is suspected and there is a guideline-concordant indication for testing independent of the planned surgery. Thompson et al., 2026, Section 4.5, Recommendation 1 supportive text
  • CCTA gave marginal improvement over clinical risk scores (Coronary CTA-VISION, N=987) and has high negative predictive value; on CCTA, single-vessel and multivessel disease carried about 3-fold and 8-fold higher perioperative MACE risk. Evidence for routine revascularization before surgery is lacking. Thompson et al., 2026, Section 4.5, Recommendation 1 supportive text
  • If a patient had a coronary artery calcium score of 0 within the past 2 years, proceeding to surgery without more testing would be reasonable. CCTA is contraindicated and may be harmful before urgent or emergency surgery. Thompson et al., 2026, Section 4.5, Synopsis
• May be considered (2b)LOE B-NRSection 9.1

  In patients with known cardiovascular disease, symptoms of cardiovascular disease, or age 65 or older with cardiovascular risk factors who are having elevated-risk noncardiac surgery, it may be reasonable to measure cardiac troponin at 24 and 48 hours after surgery to identify myocardial injury.

  Applies to

  • elevated-risk surgery
  • known CVD, CVD symptoms, or age 65 or older with cardiovascular risk factors

  ›Why

  • In a prospective cohort of 21,842 patients aged 45 or older, elevated postoperative troponin without an ischemic feature carried a 3-fold higher hazard of 30-day mortality, and with an ischemic feature a 5-fold higher hazard. Thompson et al., 2026, Section 9.1, Recommendation 1 supportive text
  • A baseline preoperative value or serial postoperative values help tell acute from chronic injury. Conventional fourth-generation or high-sensitivity assays can be used depending on availability. Thompson et al., 2026, Section 9.1, Recommendation 1 supportive text
  • Optimal management of patients found to have MINS remains uncertain, and it is unclear whether the diagnosis changes care in those already on maximal guideline-directed therapy for CAD. Thompson et al., 2026, Section 9.1, Recommendation 1 supportive text
• May be considered (2b)LOE C-LDSection 9.1

  In patients who develop MINS, antithrombotic therapy may be considered to reduce thromboembolic events.

  Applies to

  • MINS diagnosed

  ›Why

  • The MANAGE trial (1754 patients) randomized patients within 35 days of MINS to dabigatran 110 mg twice daily or placebo: major vascular events fell without more major bleeding, but minor and gastrointestinal bleeding increased. About half of patients in both arms stopped the study drug early, and the primary outcomes were changed after the trial began because of slow enrollment. Thompson et al., 2026, Section 9.1, Recommendation 4 supportive text
  • Antiplatelet therapy at hospital discharge was associated with lower 1-year mortality in a propensity-matched observational analysis. Thompson et al., 2026, Section 9.1, Recommendation 4 supportive text