Preoperative cardiac evaluation for non-cardiac surgery

Red Flags

Active cardiac condition (unstable angina, decompensated HF, severe valvular disease, significant arrhythmia) — postpone elective surgery; treat first^[1]
Recent MI (<60 days) or PCI (<6 months DES) before elective non-cardiac surgery — defer surgery if feasible; consult cardiology^[1]
Functional capacity <4 METs and elevated revised cardiac risk index (RCRI) — pursue further testing only if it will change management^[1]
Active aortic aneurysm or significant carotid disease in vascular surgery patient — coordinate timing with vascular team^[1]

Continue chronic cardiac medications^[1]
Continue beta-blockers, statins, and most antihypertensives. Hold ACE-i/ARB on day of surgery only if hypotension risk; resume promptly post-op
Antithrombotic management^[1]
Continue aspirin in most patients with established CAD. DAPT timing: defer elective surgery for 30 days post-BMS, 6 months post-DES (with newer-gen stents). Bridging anticoagulation rarely indicated — only mechanical mitral valve or recent VTE
Avoid routine pre-op coronary revascularisation^[1]
Pre-op revascularisation NOT recommended solely to reduce peri-operative cardiac events; reserved for patients meeting independent cardiac indications
Targeted stress testing^[1]
Avoid blanket stress testing; reserve for clinical scenarios where results meaningfully change management (e.g., timing of surgery, revascularisation decision)
Peri-operative beta-blocker continuation (NOT new initiation)^[1]
Continue if already on. Do NOT initiate fresh beta-blocker on day of surgery — POISE trial harm

If you take blood thinners or aspirin, do NOT stop them on your own before surgery — discuss with both your prescriber and surgeon^[1]
Bring an updated medication list to your pre-op visit including dose and timing^[1]
If new chest pain, breathlessness, or palpitations develop while waiting for surgery — same-day medical review^[1]

Active cardiac condition (unstable angina, decompensated HF, severe valvular disease, significant arrhythmia)Cardiology before proceeding with elective surgery^[1]
Recent MI <60 days, recent PCI <6 months (DES) or <30 days (BMS) requiring elective surgeryCardiology to advise timing and antithrombotic strategy^[1]
Severe aortic stenosis (mean gradient ≥40 mmHg, peak velocity ≥4 m/s) before elective non-cardiac surgeryHeart team for AVR vs proceed-with-monitoring decision^[1]

Stepwise risk assessment and selective testing before non-cardiac surgery, with judicious use of stress testing and CCTA.

1.2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM Guideline for Perioperative Cardiovascular Management for Noncardiac Surgery (2024)