Updated October 2025

Perioperative Cardiology

Preoperative Cardiac Evaluation Before Non‑Cardiac Surgery

Evidence-based, stepwise approach integrating surgical risk, patient-specific risk indices, and functional capacity to guide testing, biomarker use, and optimization. Cardiovascular testing is rarely indicated in low-risk patients; focus on identifying unstable cardiac disease, estimating major adverse cardiac event (MACE) risk, and selecting targeted investigations that would change management.

Clinical question

How should clinicians perform a preoperative cardiac evaluation for adults undergoing non-cardiac surgery to minimize perioperative major adverse cardiac events and guide testing and optimization?

perioperativecardiologyrisk stratificationRCRIfunctional capacityACC/AHAbiomarkers

Key points

Recognize active/unstable cardiac conditions first

Postpone elective surgery for acute coronary syndromes, decompensated heart failure, significant arrhythmias, or severe valvular disease until stabilized per guideline-directed therapy ^[7].

Quantify baseline risk

Use a validated index (e.g., RCRI) and surgical risk category to estimate MACE risk and guide next steps; reserve testing for elevated-risk patients with poor functional capacity (<4 METs) when results would alter care ^[2], ^[5], ^[7].

Leverage biomarkers and surveillance wisely

Consider baseline and postoperative troponin in elevated-risk patients to detect perioperative myocardial injury (PMI), which carries adverse prognosis ^[8].

Targeted imaging only

Order stress testing or echocardiography for selected patients with elevated risk, poor METs, or suspected moderate–severe valvular/ventricular dysfunction when it would change perioperative management ^[2], ^[7], ^[12].

Optimize and coordinate

Optimize medical therapy (statins, BP control), heart failure management, arrhythmias, and valve disease; plan anesthesia/monitoring with a multidisciplinary team for higher-risk procedures (e.g., major vascular surgery) ^[4], ^[7], ^[9].

Evidence highlights

27M non-cardiac surgeries; ~50,000 postoperative MI ^[13]

Annual U.S. burden

Perioperative myocardial injury linked to higher short- and long-term mortality ^[8]

PMI impact

Only if results will change management, especially with <4 METs and high-risk surgery ^[2], ^[7]

Testing principle

Stepwise Approach

Structured Preoperative Cardiac Evaluation

A concise, evidence-based pathway synthesizing landmark indices and contemporary guideline recommendations.

1) Define the surgery and urgency

Classify timing (emergent, urgent, time-sensitive, elective) and inherent surgical cardiac risk (low vs intermediate vs high). Thoracic, major abdominal, vascular, and head/neck procedures carry higher cardiac risk ^[4]. Emergent surgeries prioritize life-saving care with targeted risk mitigation ^[7].

2) Screen for active cardiac conditions

Identify acute coronary syndrome, decompensated heart failure, significant arrhythmias, and severe valvular disease. For elective cases, stabilize before surgery; consider deferral and cardiology co-management ^[7].

3) Estimate baseline MACE risk

Use the Revised Cardiac Risk Index (RCRI) (history of ischemic heart disease, heart failure, cerebrovascular disease, insulin-treated diabetes, creatinine >2 mg/dL, high-risk surgery). Event rates rise with more predictors; the RCRI remains pragmatic at the bedside ^[5]. Earlier multifactorial indices (e.g., Detsky) informed this paradigm ^[1].

4) Assess functional capacity

Evaluate METs; ≥4 METs (e.g., climbing one flight of stairs briskly) generally indicates adequate reserve. <4 METs or indeterminate capacity plus elevated surgical risk may justify further testing if it will change management ^[2], ^[7].

5) Selective testing (only if results change care)

• Stress testing for ischemia in elevated-risk patients with poor METs when revascularization or altered perioperative strategy would follow ^[2], ^[7]. • TTE if new/worsening dyspnea, suspected moderate–severe valvular disease, pulmonary hypertension, or ventricular dysfunction; focused TTE findings frequently alter perioperative plans ^[12]. Routine preop echo or stress testing in low-risk patients is discouraged ^[2], ^[7].

6) Biomarkers and surveillance

Baseline troponin (and natriuretic peptides where available) may aid risk stratification in elevated-risk patients; postoperative troponin surveillance can detect PMI, which is associated with increased short- and long-term mortality even when asymptomatic ^[8].

7) Optimize and mitigate

Continue guideline-directed medical therapy. Maintain beta-blockers if already prescribed; avoid initiating high-dose beta-blockade immediately preop. Use statins for vascular surgery or existing indications. Optimize heart failure status, rhythm control, and blood pressure. Plan anesthesia, hemodynamic monitoring, and postoperative disposition for elevated-risk patients ^[2], ^[7], ^[9].

Decision Aids

When to Test vs When to Proceed

Pair the RCRI and functional capacity with surgical risk to determine testing and monitoring.

Proceed without further cardiac testing

Low-risk surgery and/or estimated MACE risk <1% by clinical index ^[2], ^[7]

Good functional capacity (≥4 METs) without concerning symptoms ^[2]

No active or unstable cardiac conditions ^[7]

Consider noninvasive stress testing

Elevated surgical risk plus poor/unknown METs (<4) where results would alter management ^[2], ^[7]

Intermediate/high RCRI with potential to change revascularization, anesthesia plan, or monitoring ^[5], ^[7]

Order transthoracic echocardiography

New/worsening dyspnea, suspected moderate–severe valvular disease, pulmonary hypertension, or LV dysfunction ^[7], ^[12]

No routine TTE in asymptomatic, stable patients with prior normal study ^[2], ^[7]

Use cardiac biomarkers strategically

Baseline and serial postoperative troponin in elevated-risk patients to detect PMI ^[8]

Consider BNP/NT-proBNP where available to refine risk; integrate with RCRI and METs ^[2]

Optimize medical therapy

Continue beta-blockers; avoid new high-dose initiation immediately preop ^[7]

Continue statins; initiate for vascular surgery or clear indication ^[7]

Control blood pressure; manage arrhythmias and heart failure per guidelines ^[7], ^[9]

High-risk procedures planning

Thoracic, major abdominal, vascular, head/neck surgeries carry higher cardiac risk—plan invasive monitoring and postoperative level of care accordingly ^[4]

Discuss risks and goals; shared decision-making for time-sensitive cases ^[7]

References

Source material

Primary literature that informs this article.