Evaluation of Cardiac Risk Prior To Noncardiac Surgery

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Evaluation of cardiac risk prior to noncardiac surgery

Authors: Steven L Cohn, MD, MACP, SFHM, Lee A Fleisher, MD
Section Editor: Patricia A Pellikka, MD, FACC, FAHA, FASE
Deputy Editors: Jane Givens, MD, Gordon M Saperia, MD
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: May 2020. | This topic last updated: Feb 11, 2020.
INTRODUCTION
Many patients undergoing major noncardiac surgery are at risk for a cardiovascular event. The
risk is related to patient- and surgery-specific characteristics. Identification of increased risk
provides the patient (and surgeon) with information that helps them better understand the
benefit-to-risk ratio of a procedure and may lead to interventions that decrease risk.
This topic will review the initial preoperative cardiac evaluation, which includes an attempt to
quantify risk. The management of cardiac risk (in an attempt to reduce morbidity and mortality)
and issues related to the perioperative evaluation and management of heart failure or
myocardial infarction (MI) are discussed separately. (See "Management of cardiac risk for
noncardiac surgery" and "Perioperative myocardial infarction or injury after noncardiac surgery"
and "Perioperative management of heart failure in patients undergoing noncardiac surgery".)
INCIDENCE
The incidence of an adverse cardiovascular outcome is related to the baseline risk.
A 1995 review of major published series found that the pooled average rates of selective
outcome of myocardial infarction (MI) and cardiac death varied with the population studied [1]:
● Among unselected surgical patients over age 40 – Perioperative MI in 1.4 percent and
cardiac death in 1.0 percent.
● Among consecutive surgical patients with some selection criteria – Perioperative MI in 3.2
percent and cardiac death in 1.7 percent.
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In a retrospective study of 663,635 adults not taking beta blockers who underwent major
noncardiac surgery in 2000 and 2001, in-hospital mortality increased progressively from 1.4 to
7.4 percent according to a preoperative assessment of risk using the revised cardiac risk index
(RCRI) described below (table 1) [2]. (See 'Revised cardiac risk index' below.)
A 2016 study, using information in a large administrative database of United States hospital
admissions (2004 to 2013), found a 3 percent incidence of major adverse cardiovascular and
cerebrovascular events (in-hospital, all-cause death, acute MI, or acute ischemic stroke) [3].
These events were most common after vascular, thoracic, and transplant surgery.
Patients with underlying cardiovascular disease, including peripheral artery disease or stroke,
have an increased risk of perioperative cardiac complications compared with patients without
extant atherosclerosis for two reasons:
● They constitute a selected population with a high incidence of significant coronary artery
disease [4,5]. In addition, left ventricular systolic dysfunction (left ventricular ejection
fraction ≤40 percent) is five times more common in patients with cerebrovascular disease
or peripheral artery disease compared with matched controls [6].
● Physiologic factors associated with surgery predisposed to myocardial ischemia, which is

more pronounced in patients with underlying coronary disease. These include volume
shifts and blood loss, enhanced myocardial oxygen demand from elevations in heart rate
and blood pressure secondary to stress from surgery, and an increase in postoperative
platelet reactivity [7].
Despite the increased risk in the population with vascular disease, the rates of MI and death
have decreased over time. For example, perioperative mortality after carotid endarterectomy is
approximately 1 percent and for abdominal aortic aneurysm repair is <3 percent [8].
OUR APPROACH
All patients scheduled to undergo noncardiac surgery should have an assessment of the risk of
a cardiovascular perioperative cardiac event [9,10]. An algorithm developed for use in patients
with known coronary artery disease or at high risk can be used for this purpose (algorithm 1).
The rationale for this recommendation and a detailed discussion of risk assessment tools
(models) are presented below. (See 'Risk assessment' below.)
Very high-risk patients and those undergoing emergency or urgent surgery are approached
somewhat differently.
Very high-risk patients — Patients with recent MI (60 days) or unstable angina,
decompensated heart failure, high-grade arrhythmias, or hemodynamically important valvular
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heart disease (aortic stenosis in particular) are at very high risk for perioperative MI, heart
failure, ventricular fibrillation or primary cardiac arrest, complete heart block, and cardiac death.
All such patients should be optimally treated, with possible referral to a cardiologist for further
evaluation and management [11]. (See "Noncardiac surgery in patients with aortic stenosis"
and "Perioperative management of heart failure in patients undergoing noncardiac surgery",
section on 'Risk classification by heart failure syndrome'.)
Emergency or urgent surgery — Patients who require emergency or urgent surgery are at
increased risk of a perioperative cardiovascular event at any level of baseline risk. In these
cases, risk indices derived from elective surgery cohorts are not accurate, although they may
provide an estimate of the minimal risk.
In many cases, there is not sufficient time for an extensive evaluation of the severity of a
patient’s cardiovascular problem, and in most cases the benefit of proceeding with surgery
outweighs the risk of waiting to perform additional testing. In the absence of preoperative
assessment because of the minimal time available before surgery, clinicians must be available
postoperatively to help manage the possible cardiovascular complications in at-risk patients.
INITIAL PREOPERATIVE EVALUATION
Once a determination is made that noncardiac surgery will be considered, the patient should be
evaluated for the risk of a cardiovascular complication. This evaluation is generally performed
by a primary care clinician. The information obtained is used to assess risk. In patients
assessed to be at elevated (intermediate or high) cardiovascular risk, a referral to a cardiologist
for further evaluation may be indicated.
At the time of the initial preoperative evaluation, the clinician should inquire about symptoms
such as angina, dyspnea, syncope, and palpitations as well as a history of heart disease,
including ischemic, valvular, or cardiomyopathic disease, and a history of hypertension,
diabetes, chronic kidney disease, and cerebrovascular or peripheral artery disease. The role of
functional status as traditionally assessed by the clinician is discussed below. (See 'Functional
status/capacity' below.)
The physical examination should focus on the cardiovascular system and include blood
pressure measurements, auscultation of the heart and lungs, abdominal palpation, and
examination of the extremities for edema and vascular integrity. Important findings include
evidence of heart failure or a murmur suspicious for hemodynamically significant valvular heart
disease. (See 'Risk factors' below.)
Similar to recommendations made in the 2014 American College of Cardiology/American Heart

Association (ACC/AHA) and European Society of Cardiology/European Society of
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Anesthesiology (ESC/ESA) guidelines on noncardiac surgery, we obtain an electrocardiogram

(ECG) in many patients with known cardiovascular disease, significant arrhythmia, or significant
structural heart disease unless the patient is undergoing low-risk surgery (surgery associated
with less than 1 percent morbidity/mortality such as ambulatory surgery) [9,10,12]. A
preoperative ECG can be obtained in asymptomatic patients without known cardiovascular
disease, but it is rarely helpful. Some ECG abnormalities seem to be associated with a worse
prognosis in observational studies, but the association is inconsistent across studies. ECG
abnormalities are not part of either the revised cardiac risk index (RCRI) or the National
Surgical Quality Improvement Plan (NSQIP) because of the lack of prognostic specificity
associated with these findings. (See 'Risk assessment' below.)
The rationale for obtaining a preoperative ECG comes from the utility of having a baseline ECG
should a postoperative ECG be abnormal.
For those patients who receive a preoperative ECG, it should be evaluated for the presence of
Q waves or significant ST-segment elevation or depression, which raises the possibility of
myocardial ischemia or infarction, left ventricular hypertrophy, QTc prolongation, bundle-branch
block, or arrhythmia [13].
Functional status/capacity — Cardiac functional status or capacity, as determined by doctors

assessing patients with a brief set of questions, has been thought to be positively associated
with postoperative outcomes. This assessment has been included in many risk models. None
of the risk models discussed below are optimally constructed. We use the more standardized
Duke Activity Status Index (DASI) standardized questionnaire for many patients. (See 'Risk
assessment' below.)
Functional status can be expressed in metabolic equivalents (1 MET is defined as 3.5 mL O2

uptake/kg per min, which is the resting oxygen uptake in a sitting position). The ability to
achieve four METs of activity without symptoms is thought to be a good prognostic indicator
[14].
Various activity scales provide the clinician with a set of questions to determine a patient's
functional capacity [15]. Indicators of functional status include the following:
● Can take care of self, such as eat, dress, or use the toilet (1 MET)
● Can walk up a flight of steps or a hill or walk on level ground at 3 to 4 mph (4 METs)
● Can do heavy work around the house, such as scrubbing floors or lifting or moving heavy
furniture, or climb two flights of stairs (between 4 and 10 METs)
● Can participate in strenuous sports such as swimming, singles tennis, football, basketball,
and skiing (>10 METs)
The 2018 METS prospective cohort study concluded that subjectively assessed preoperative
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functional capacity did not accurately identify patients with poor cardiopulmonary fitness or
predict postoperative morbidity or mortality [16]. In this study of 1401 patients scheduled for
major noncardiac surgery and who had one or more risk factors for cardiac complications, the
predictive ability of the subjective assessment of functional capacity (in METS) was compared
with the Duke Activity Status Index (DASI) standardized questionnaire(table 2), formal
cardiopulmonary exercise testing (CPET), and measurement of N-Terminal pro-brain natriuretic
peptide concentrations. These three comparators have been previously validated as capable of
predicting postoperative cardiovascular events, although CPET may offer some advantages for
predicting all-cause complications as opposed to cardiovascular events alone (see "Natriuretic
peptide measurement in non-heart failure settings", section on 'Postoperative complications').
The primary outcome was death or myocardial infarction within 30 days after surgery.
Subjective assessment of functional capacity had a 19.2 percent sensitivity and a 94.7 percent
specificity for predicting the inability to attain four metabolic equivalents during CPET. Stated
another way, subjective assessment resulted in a substantial misclassification of high-risk
patients as low risk [17]. Only DASI scores were associated with successfully predicting the
primary outcome (adjusted odds ratio 0.96, 95% CI 0.83-0.99). A DASI score of <34 was
associated with an increased risk of 30-day death, myocardial infarction, and moderate to
severe complications [18]. Peak oxygen consumption was associated with moderate to severe
complications, but neither it nor anaerobic threshold was predictive of the primary outcome.
The results of the METS study make us less confident that risk assessment models/tools
/algorithms that include subjective assessment of functional capacity are optimally constructed.
(See 'Risk assessment' below.)
RISK FACTORS
The following clinical and surgery-specific factors have been associated with an increase in
perioperative risk of a cardiovascular event and are used in one or both of the models
discussed below (revised cardiac risk index [RCRI] or the Gupta myocardial infarction or
cardiac arrest [MICA] calculator derived from the American College of Surgeons National
Surgical Quality Improvement Plan [NSQIP]). The newer NSQIP calculator includes 20 patient
risk factors in addition to the surgical procedure (see 'Risk assessment' below):
● Surgery-specific risk (RCRI and NSQIP) – The reported rate of cardiac death or nonfatal
myocardial infarction (MI) is more than 5 percent in high-risk procedures, between 1 and 5
percent in intermediate-risk procedures, and less than 1 percent in low-risk procedures
(table 3). Institutional and/or individual surgeon experience with the procedure may
increase or lower the risk. Emergency surgery is associated with particularly high risk, as
cardiac complications are two to five times more likely than with elective procedures (table
4). This issue is discussed in greater detail separately. (See "Preanesthesia evaluation for
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noncardiac surgery", section on 'Surgical risk'.)
● History of ischemic heart disease (RCRI).
● History of heart failure (RCRI).
● History of cerebrovascular disease (RCRI).
● Insulin dependent diabetes mellitus (RCRI).
● Preoperative serum creatinine ≥2.0 mg/dL (RCRI) or >1.5 mg/dL (NSQIP).
● Increasing age (NQSIP).
● American Society of Anesthesiologist class (NSQIP).
● Preoperative functional status (NSQIP). (See 'Functional status/capacity' above.)
While not included in the risk factors above, the following patient characteristics have been
associated with increased risk:
● Atrial fibrillation – A retrospective, administrative database study demonstrated an

association between a history of prior admission for atrial fibrillation and postoperative
complications [19]. The risk associated with atrial fibrillation was higher than that
associated with a diagnosis of coronary artery disease.
● Obesity – Obese patients are at increased risk for adverse cardiovascular events at the
time of noncardiac surgery. However, obesity has not been shown to be a predictor
independent of end-organ damage. (See "Obesity: Association with cardiovascular
disease".)
The issue of whether the preoperative approach to obese patients should differ from that in
the general population is uncertain [20].
RISK ASSESSMENT
Overview — All patients scheduled to undergo noncardiac surgery should have an initial
assessment of the risk (in percent) of a cardiovascular perioperative cardiac event using
validated models that typically include information from the history, physical examination,
electrocardiogram, and type of surgery [9,10] (see 'Risk factors' above). The purpose of this
assessment is to help the patient and health care providers weigh the benefits and risks of the
surgery and optimize the timing of the surgery. On occasion, risk assessment will uncover
undiagnosed problems or suboptimally treated prior conditions that need attention.
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There is wide variability in the predicted risk of cardiac complications using different risk-
prediction tools as each was developed in different populations undergoing various surgical
procedures and had different definitions of risk factors, postoperative complications, and
timeframes for follow-up, so there cannot be a valid comparison [21,22]. Additionally,
subsequent studies evaluating these tools also often used them in a different setting than
originally derived (specific patient or procedure groups, eg, older adults, cardiac history or risk
factors, vascular or orthopedic surgery) or outcomes not in the original models (eg, myocardial
injury, stroke, or overall mortality, urgent/emergency surgery). We caution users of
commercially available online calculators as they may overestimate predicted risk compared
with one of our recommended calculators using original study data.
We use either the revised cardiac risk index (RCRI), also referred to as the Lee index (table 1)
[23], or the American College of Surgeons National Surgical Quality Improvement Program
(NSQIP) risk model calculator [24]. The RCRI is simpler and has been widely used and
validated over the past 15 years. The NSQIP calculator is more complex, requiring calculation
through an online tool, and has yet to be validated in other populations. A simpler tool also
derived from the NSQIP database is the Gupta myocardial infarction or cardiac arrest (MICA)
calculator. The MICA calculator outperformed the RCRI in some circumstances, and the newer
NSQIP surgical risk calculator is more comprehensive and procedure-specific. However, as
mentioned previously, neither of these has yet to be validated externally. Furthermore, direct
comparison of the various tools is difficult due to their different definitions of risk factors,
complications, and outcomes [25]. Therefore, the optimal tool incorporates local factors into the
preoperative workflow. In addition, based on the 2018 METS study, we have concerns
regarding the predictive ability of these tools (see 'Functional status/capacity' above).
Practitioners should become familiar with one model and use it regularly.
These models provide the user with the risk of a cardiac complication in percent (table 5). For
patients at low risk (<1 percent), no further testing is indicated. For patients at higher risk,
caregivers need to ask the question whether further cardiovascular testing will change
management and hopefully improve the outcome. In most cases, the reason to perform
additional testing will be based not on the desire to lower risk at the time of surgery but rather
to lower long-term risk. That is, the patient should have additional testing done irrespective of
the need for surgery. There are few circumstances in which testing should be performed solely
because the patient has upcoming surgery.
The risk will determine whether surgery should proceed without further cardiovascular testing;
be postponed pending further testing such as stress testing or echocardiography; be changed
to a lesser risk procedure (if possible) or a non-surgical alternative (eg, radiation and/or
chemotherapy or palliative care); or be cancelled so that a procedure such as coronary
revascularization or heart valve replacement can take place.
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We do not recommend using older models such as the original Goldman cardiac risk index [26],
the Detsky modified risk index, or the Eagle criteria [27-32]. Risk assessment should include
information from the chosen scoring system with the inherent risk of the surgery.
The value of all these risk indicators (models) may be diminishing over time, as the
cardiovascular risk of surgery is declining [33]. This may result from the changing nature of
postoperative myocardial infarction (MI), from a type 1, plaque rupture, MI to a type 2,
hemodynamic MI. In the POISE trial of 8351 patients at high risk for or with atherosclerosis
undergoing noncardiac surgery, only 35 (0.4 percent) required coronary revascularization
postoperatively [34]. Thus, the value of risk prediction models may be waning as the original
end point of interest decreases and newer studies are focusing on the endpoint of myocardial
injury after noncardiac surgery. (See "Perioperative myocardial infarction or injury after
noncardiac surgery", section on 'Definitions of myocardial infarction and myocardial injury'.)
Gupta MICA NSQIP database risk model — The NSQIP database was used to determine risk
factors associated with intraoperative/postoperative MI or cardiac arrest [35]. Among over
200,000 patients who underwent surgery in 2007, 0.65 percent developed perioperative MI or
cardiac arrest. On multivariate logistic regression analysis, five factors were identified as
predictors of MI or cardiac arrest:
● Type of surgery
● Dependent functional status
● Abnormal creatinine
● American Society of Anesthesiologists’ class (table 6)
● Increased age
A risk model was developed using these five factors and subsequently validated on a 2008
data set (n = 257,385). The risk model had a relatively high predictive accuracy (C statistic of
0.874) and outperformed the RCRI (C statistic of 0.747). An easy-to-use calculator was
developed from this model.
Revised cardiac risk index — The RCRI was published in 1999 and has been used
worldwide since then [23]. In the derivation of the index, 2893 patients (mean age 66)
undergoing elective major noncardiac procedures (with an expected length of stay >2 days)
were monitored for major cardiac complications (cardiac death, acute MI, pulmonary edema,
ventricular fibrillation/cardiac arrest, and complete heart block) (table 1). The index was
validated in a cohort of 1422 similar individuals. The predictive value was significant in all types
of elective major noncardiac surgery except for abdominal aortic aneurysm surgery (figure 1).
A 2009 systematic review evaluated the ability of the RCRI to predict cardiac complications and
mortality after major noncardiac surgery in various populations and settings [36]. The RCRI
performed moderately well in distinguishing patients at low compared with high risk for all types
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of noncardiac surgery but was somewhat less accurate in patients undergoing only vascular
noncardiac surgery. In addition, RCRI did not predict all-cause mortality well. However, this is
expected, as it does not capture risk factors for noncardiac causes of perioperative mortality
and only one-third of perioperative deaths are due to cardiac causes.
The risk of major cardiac complications (cardiac death, nonfatal MI, nonfatal cardiac arrest,
postoperative cardiogenic pulmonary edema, complete heart block) varied according to the
number of risk factors. The following combined rates of nonfatal MI, nonfatal cardiac arrest, and
cardiac death were seen in various studies [37]:
● No risk factors – 0.4 percent

● One risk factor – 1 percent
● Two risk factors – 2.4 percent
● Three or more risk factors – 5.4 percent
The percentages presented above may underestimate a risk that includes other cardiovascular
outcomes such as complete heart block or heart failure.
● In a large retrospective analysis on mortality, the perioperative risk was evaluated in

663,665 adults with no contraindications to beta blockers who underwent major noncardiac
surgery in 2000 and 2001 at 329 hospitals in the United States [2]. In-hospital mortality in
patients not treated with beta blockers increased progressively from 1.4 percent at a score
of 0 to 7.4 percent at a score ≥4. The rate of mortality in this study was higher at the same
RCRI than the combined endpoint of cardiac death, nonfatal MI, and nonfatal cardiac
arrest in the earlier RCRI (Goldman) population [37].
● In the PeriOperative ISchemic Evaluation (POISE) randomized trial of over 8000 patients
undergoing noncardiac surgery between 2002 and 2007, the combined rate of
cardiovascular death, nonfatal MI, and nonfatal cardiac arrest was 6.9 percent in the
placebo group [38]. The majority of these individuals were RCRI 1 or 2. (See
"Management of cardiac risk for noncardiac surgery", section on 'Beta blockers'.)
There are several factors that probably contribute to the higher event rate in these two later
studies:
● The original RCRI risk prediction model did not take all-cause mortality into account [23]
● RCRI only included in-patient complications, not 30-day event rates.
● In earlier studies, creatine kinase-MB fraction was used to diagnose MI, rather than
troponins, which are more sensitive. (See "Troponin testing: Analytical considerations".)
● The type of MI after surgery is changing. The incidence of a type 1, plaque rupture, MI is
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decreasing while type 2, hemodynamic MI is increasing.
One study reexamined the original six risk factors to confirm their validity in a large modern
prospective database, including 9519 patients aged ≥50 undergoing elective non-cardiac
surgery with an expected length of stay ≥2 days at two major tertiary-care teaching hospitals
[39]. Compared with the RCRI, a simplified five-factor model ("reconstructed RCRI") using high-
risk type of surgery, history of ischemic heart disease, congestive heart failure, cerebrovascular
disease, and preoperative glomerular filtration rate (GFR) <30 mL/minute instead of serum
creatinine >2 mg/dL (but not including diabetes or insulin treatment) resulted in superior
prediction of major cardiac complications following elective noncardiac surgery.
AUB-POCES index — The 2019 American University of Beirut-Pre-Operative Cardiovascular

Evaluation Study (AUB-POCES) prospectively derived and validated a new preoperative
cardiovascular risk index (CVRI) [40]. Multivariate logistic regression analysis in the derivation
cohort identified six predictors of risk: age ≥75 years, history of heart disease, symptoms of
angina or dyspnea, hemoglobin <12 mg/dL, vascular surgery, and emergency surgery. Patients
were assigned a score of 0, 1, 2, 3, and >3 based on the number of predictors. The incidence
of the primary outcome of death, MI, or stroke at 30 days increased steadily across the
increasing scores, in both the derivation (0, 0.5, 2.0. 5.6, and 15.7 percent, respectively) and
validation (0.3, 1.6, 5.6, 11.0, and 17.5 percent, respectively) cohorts. The area under the
receiver operator characteristic curve was significantly better than that for RCRI (0.9 versus
0.79) discussed above, although outcomes differed (see 'Revised cardiac risk index' above).
CVRI used 30-day rather than in-hospital outcomes, used all-cause rather than cardiac
mortality, and included stroke. Patients with emergency surgery had been excluded for
derivation of RCRI. An advantage of CVRI is its ease of use. Additional validation in other
populations is needed.
VSGNE risk index — As the RCRI, discussed directly above, did not perform well in patients
undergoing vascular surgery, the Vascular Study Group of New England (VSGNE) developed a
risk index specifically for those patients [41]. However, we do not use this index in our
practices.
In multivariate analysis of the VSGNE cohort, independent predictors of adverse cardiac events
(MI, arrhythmia, and heart failure, but not mortality) were increasing age (odds ratio [OR] 1.7 to
2.8), smoking (OR 1.3), insulin-dependent diabetes (OR 1.4), coronary artery disease (OR 1.4),
congestive heart failure (OR 1.9), abnormal cardiac stress test (OR 1.2), long-term beta-blocker
therapy (OR 1.4), chronic obstructive pulmonary disease (OR 1.6), and creatinine ≥1.8 mg/dL
(OR 1.7). Prior cardiac revascularization was protective (OR 0.8). This calculator is no longer
available online and has been replaced by the VQI calculators discussed directly below. The
RCRI substantially underestimated in-hospital cardiac event in patients undergoing elective or
urgent vascular surgery, especially after lower-extremity bypass, endovascular abdominal aortic
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aneurysm repair, and open infrarenal abdominal aortic aneurysm. This risk index also has not
been externally validated and did not include mortality as an end point.
VQI cardiac risk index — Several models were developed to predict risk of postoperative
MI/myocardial injury after noncardiac surgery (MINS) during hospitalization after various
vascular surgery procedures based on 88,791 nonemergency operations from the Vascular
Quality Initiative (VQI) registry. These procedures included carotid endarterectomy, infrainguinal
bypass, suprainguinal bypass, endovascular aneurysm repair, and open abdominal aortic
aneurysm repair. An all-procedure and four procedure-specific risk calculators were created
using multivariate analysis based on a derivation cohort from 2012 to 2014 (n = 61,236) and
validated using a cohort (n = 27,555) from 2015 to 2016.
Predictors of MI/MINS in the all-procedure model included age, operation type, coronary artery
disease, congestive heart failure, diabetes, creatinine concentration >1.8 mg/dL, stress test
status, and body mass index (area under the curve [AUC] 0.75; 95% CI, 0.73-0.76).This model
was less accurate than the procedure-specific calculators which included unique predictors.
These calculators are available online [42,43].
NSQIP universal surgical risk calculator — Based on 1,414,006 patients encompassing

1557 unique CPT codes, a universal surgical risk calculator model [24] has been developed
using a web-based tool consisting of 20 patient factors plus the surgical procedure. This model
had excellent performance for mortality (C statistic = 0.944; Brier score = 0.011 [where scores
approaching 0 are better]), morbidity (C statistic = 0.816, Brier score = 0.069), and six
additional complications (C statistics >0.8). While more comprehensive than the other risk
calculators, it is more cumbersome, which may limit its use. In addition, this calculator has not
yet been externally validated. However, it is useful as a decision aid and informed consent tool
for clinicians and patients. This calculator is available online.
MANAGEMENT BASED ON RISK
We use estimated risk (see 'Risk assessment' above) to categorize patients into low- or higher-
risk groups. (See "Management of cardiac risk for noncardiac surgery".)
Low-risk patients — Patients whose estimated risk of death is less than 1 percent are labeled
as being low risk and require no additional cardiovascular testing.
Higher-risk patients — Patients whose risk of death is 1 percent or higher may require
additional cardiovascular evaluation. Often, these are patients with known or suspected
coronary artery or valvular heart disease. Further evaluation may include stress testing or
echocardiography, or cardiologist consultation. We generally perform these tests if they are
indicated for the patient even if they were not having surgery. Many studies of patients not at
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low risk have shown that performing some form of stress testing can further stratify the risk of
an adverse perioperative event [20,30,31,44-53]. However, no study has shown that
interventions performed consequent to the results of the test improves outcomes.
When we consider further cardiovascular evaluation for higher-risk patients, we use the
approach suggested in the 2014 American College of Cardiology/American Heart Association
(ACC/AHA) guideline of perioperative cardiovascular evaluation and management of patients
undergoing noncardiac surgery [9,10]. In this approach, the patient’s functional capacity plays
an important role (algorithm 1). In patients who can perform ≥4 METs of activity, we do not
order additional tests. For those whose functional capacity is lower or unknown, additional
testing may be indicated if it will influence perioperative care.
FURTHER CARDIAC TESTING
In patients with known or suspected heart disease (ie, cardiovascular disease, significant
valvular heart disease, symptomatic arrhythmias), we perform further cardiac evaluation (eg,
stress testing) only if it is indicated in the absence of proposed surgery. There is no evidence
that further diagnostic or prognostic evaluation improves surgical outcomes. Preoperative
cardiac evaluation and testing may differ for patients being evaluated for liver or kidney
transplant. (See "Liver transplantation in adults: Patient selection and pretransplantation
evaluation", section on 'Cardiac stress testing'.)
For patients in whom a decision has been made to perform additional cardiovascular testing, its
timing should be determined by the urgency of the clinical situation.
Stress testing — Stress testing is not indicated in the perioperative patient solely because of
the surgery if there is no other indication. (See "Stress testing for the diagnosis of obstructive
coronary heart disease" and "Stress testing in patients with left bundle branch block or a paced
ventricular rhythm" and "Noninvasive testing and imaging for diagnosis in patients at low to
intermediate risk for acute coronary syndrome" and "Screening for coronary heart disease in
patients with diabetes mellitus" and "Stress testing to determine prognosis of coronary heart
disease".)
However, some experts routinely obtain preoperative stress imaging in patients who are
scheduled for major vascular surgery.
Stress testing with exercise (with or without imaging) and pharmacologic stress testing with
imaging have been well studied in patients scheduled to undergo noncardiac surgery. Although
there is a clear relationship between the degree of myocardial ischemia found and prognosis,
there is no evidence that prophylactic revascularization, in addition to recommended medical
therapy, to prevent ischemia at the time of surgery improves outcomes [44,53-61].
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Resting echocardiography — Resting echocardiography is not indicated in the perioperative

patient unless there is another indication, such as to evaluate valve function in patients with a
murmur or left ventricular systolic function in patients with heart failure or dyspnea of unknown
cause. (See "Transesophageal echocardiography: Indications, complications, and normal
views" and "Echocardiographic evaluation of prosthetic heart valves" and "Role of
echocardiography in atrial fibrillation" and "Echocardiographic evaluation of the aortic valve"
and "Echocardiographic evaluation of the mitral valve".)
The presence of significant left ventricular systolic dysfunction or severe valvular heart disease
is associated with a worse outcome, particularly postoperative heart failure, at the time of
noncardiac surgery [11,45,62-66].
24-hour ambulatory monitoring — As with echocardiography and stress testing, we do not

recommend 24-hour ambulatory monitoring for perioperative diagnostic or prognostic purposes
if it is not otherwise indicated. Its use has not been shown to improve outcomes in this setting
[1,67,68]. The indications for 24-hour ambulatory monitoring are discussed elsewhere and are
primarily for patients with syncope or significant bradycardia or tachycardia if not previously
evaluated. (See "Ambulatory ECG monitoring" and "Evaluation of palpitations in adults" and
"Premature ventricular complexes: Clinical presentation and diagnostic evaluation" and
"Supraventricular premature beats" and "Cardiac evaluation of the survivor of sudden cardiac
arrest" and "Sustained monomorphic ventricular tachycardia: Clinical manifestations, diagnosis,
and evaluation" and "Syncope in adults: Risk assessment and additional diagnostic evaluation",
section on 'Introduction'.)
Preoperative BNP — Brain natriuretic peptide (BNP) is a natriuretic hormone that is released
primarily from the heart. It is elevated in many pathologic conditions. (See "Natriuretic peptide
measurement in heart failure" and "Natriuretic peptide measurement in non-heart failure
settings".)
Evidence is increasing that a N-terminal pro-B-type natriuretic peptide (NT-proBNP) level may
improve preoperative risk prediction when used in conjunction with recommended risk models
such as the revised cardiac risk index (RCRI) or the National Surgical Quality Improvement
Program (NSQIP) myocardial infarction and cardiac arrest (MICA) risk index [69,70]. (See 'Our
approach' above.)
In a nested substudy within the prospective VISION cohort study, 10,402 patients having
inpatient noncardiac surgery had NT-proBNP measured before surgery [71] (see "Perioperative
myocardial infarction or injury after noncardiac surgery", section on 'Incidence'). In multivariable
analyses, increasing NT-proBNP values were associated with an independent and incremental
risk of vascular death and myocardial injury or infarction within 30 days of surgery. Adding NT-
proBNP to clinical stratification using the RCRI model improved cardiac risk predication
13 de 32 18/06/2020 11:50
compared with RCRI alone.
We do not recommend routinely using NT-proBNP until it has been validated in other large
cohorts and its use is associated with improved clinical outcomes. It may be of value in patients
being considered for possible stress testing where a low value would be helpful in downgrading
the estimated risk.
Troponin — The potential role of troponin testing in perioperative risk stratification is discussed
elsewhere. (See "Perioperative myocardial infarction or injury after noncardiac surgery", section
on 'Troponin'.)
RECOMMENDATIONS OF OTHERS
Our approach to the evaluation of patients scheduled to undergo noncardiac surgery is

generally similar to that presented in the 2014 American College of Cardiology/American Heart
Association (ACC/AHA) and European Society of Cardiology/European Society of
Anesthesiology (ESC/ESA) guidelines on noncardiac surgery [9,10,12]. Despite collaborative
efforts of the two societies to minimize discrepancies between their guidelines, there are
differences in recommendations. The Canadian Cardiovascular Society Guidelines on
perioperative cardiac risk assessment and management for patients who undergo noncardiac
surgery take an alternative approach and focus on using biomarker elevation such as
N-terminal pro-B-type natriuretic peptide (NT-proBNP) or brain natriuretic peptide (BNP) as the
key determinant of further evaluation [72]. The differences between the Societal Guidelines
have been discussed in more detail elsewhere [73]. We prefer the algorithm and
recommendations in the ACC/AHA guideline (algorithm 1).
SOCIETY GUIDELINE LINKS
Links to society and government-sponsored guidelines from selected countries and regions
around the world are provided separately. (See "Society guideline links: Perioperative
cardiovascular evaluation and management" and "Society guideline links: Preoperative medical
evaluation and risk assessment".)
SUMMARY AND RECOMMENDATIONS
● All patients scheduled to undergo noncardiac surgery should have an assessment of the
risk of a cardiovascular perioperative cardiac event (algorithm 1). The patient’s functional
status is an important determinant of risk. (See 'Our approach' above.)
14 de 32 18/06/2020 11:50
● Identification of risk factors is derived from the history and physical examination; the type
of proposed surgery influences the risk of perioperative cardiac event. (See 'Initial
preoperative evaluation' above.)
● We use either the revised cardiac risk index (RCRI), also referred to as the Lee index, or
the American College of Surgeons National Surgical Quality Improvement Program
(NSQIP) risk prediction rule to establish the patient’s risk. (See 'Risk assessment' above.)
● We obtain an electrocardiogram (ECG) in patients with cardiac disease (except in those

undergoing low-risk surgery) in large part to have a baseline available should a
postoperative test be abnormal. (See 'Initial preoperative evaluation' above.)
● For patients with known or suspected heart disease (ie, cardiovascular disease, significant
valvular heart disease, symptomatic arrhythmias), we only perform further cardiac
evaluation (echocardiography, stress testing, or 24-hour ambulatory monitoring) if it is
indicated in the absence of proposed surgery. (See 'Further cardiac testing' above.)
ACKNOWLEDGEMENT
The editorial staff at UpToDate would like to acknowledge James P Morgan, MD, PhD, and
Jonathan B Shammash, MD, who contributed to an earlier version of this topic review.
The editorial staff at UpToDate would also like to acknowledge Emile Mohler III, MD, now
deceased, who contributed to an earlier version of this topic review.
Use of UpToDate is subject to the Subscription and License Agreement.
REFERENCES
1. Mangano DT, Goldman L. Preoperative assessment of patients with known or suspected

coronary disease. N Engl J Med 1995; 333:1750.
2. Lindenauer PK, Pekow P, Wang K, et al. Perioperative beta-blocker therapy and mortality
after major noncardiac surgery. N Engl J Med 2005; 353:349.
3. Smilowitz NR, Gupta N, Ramakrishna H, et al. Perioperative Major Adverse

Cardiovascular and Cerebrovascular Events Associated With Noncardiac Surgery. JAMA
Cardiol 2017; 2:181.
4. Criqui MH, Langer RD, Fronek A, et al. Mortality over a period of 10 years in patients with
15 de 32 18/06/2020 11:50
peripheral arterial disease. N Engl J Med 1992; 326:381.
5. Wong T, Detsky AS. Preoperative cardiac risk assessment for patients having peripheral
vascular surgery. Ann Intern Med 1992; 116:743.
6. Kelly R, Staines A, MacWalter R, et al. The prevalence of treatable left ventricular systolic
dysfunction in patients who present with noncardiac vascular episodes: a case-control
study. J Am Coll Cardiol 2002; 39:219.
7. Stampfer MJ, Grodstein F, Bechtel S. Postmenopausal estrogen and cardiovascular

disease. Contemp Intern Med 1994; 6:47.
8. Finks JF, Osborne NH, Birkmeyer JD. Trends in hospital volume and operative mortality
for high-risk surgery. N Engl J Med 2011; 364:2128.
9. Fleisher LA, Fleischmann KE, Auerbach AD, et al. 2014 ACC/AHA guideline on
perioperative cardiovascular evaluation and management of patients undergoing
noncardiac surgery: a report of the American College of Cardiology/American Heart
Association Task Force on practice guidelines. J Am Coll Cardiol 2014; 64:e77.
noncardiac surgery: executive summary: a report of the American College of
Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation
2014; 130:2215.
11. Tashiro T, Pislaru SV, Blustin JM, et al. Perioperative risk of major non-cardiac surgery in
patients with severe aortic stenosis: a reappraisal in contemporary practice. Eur Heart J
2014; 35:2372.
12. Kristensen SD, Knuuti J, Saraste A, et al. 2014 ESC/ESA Guidelines on non-cardiac
surgery: cardiovascular assessment and management: The Joint Task Force on non-
cardiac surgery: cardiovascular assessment and management of the European Society of
Cardiology (ESC) and the European Society of Anaesthesiology (ESA). Eur Heart J 2014;
35:2383.
13. van Klei WA, Bryson GL, Yang H, et al. The value of routine preoperative
electrocardiography in predicting myocardial infarction after noncardiac surgery. Ann Surg
2007; 246:165.
16 de 32 18/06/2020 11:50
noncardiac surgery: a report of the American College of Cardiology/American Heart

Association Task Force on Practice Guidelines. Circulation 2014; 130:e278.
15. Eagle KA, Berger PB, Calkins H, et al. ACC/AHA guideline update for perioperative
cardiovascular evaluation for noncardiac surgery--executive summary: a report of the
American College of Cardiology/American Heart Association Task Force on Practice
Guidelines (Committee to Update the 1996 Guidelines on Perioperative Cardiovascular
Evaluation for Noncardiac Surgery). J Am Coll Cardiol 2002; 39:542.
16. Wijeysundera DN, Pearse RM, Shulman MA, et al. Assessment of functional capacity
before major non-cardiac surgery: an international, prospective cohort study. Lancet
2018; 391:2631.
17. Biccard BM. The clinical utility of preoperative functinal assessment. Lancet 2018; :2580.
18. Wijeysundera DN, Beattie WS, Hillis GS, et al. Integration of the Duke Activity Status
Index into preoperative risk evaluation: a multicentre prospective cohort study. Br J
Anaesth 2020; 124:261.
19. van Diepen S, Bakal JA, McAlister FA, Ezekowitz JA. Mortality and readmission of
patients with heart failure, atrial fibrillation, or coronary artery disease undergoing
noncardiac surgery: an analysis of 38 047 patients. Circulation 2011; 124:289.
20. Poirier P, Alpert MA, Fleisher LA, et al. Cardiovascular evaluation and management of
severely obese patients undergoing surgery: a science advisory from the American Heart
Association. Circulation 2009; 120:86.
21. Glance LG, Faden E, Dutton RP, et al. Impact of the Choice of Risk Model for Identifying
Low-risk Patients Using the 2014 American College of Cardiology/American Heart
Association Perioperative Guidelines. Anesthesiology 2018; 129:889.
22. Cohn SL, Fernandez Ros N. Comparison of 4 Cardiac Risk Calculators in Predicting
Postoperative Cardiac Complications After Noncardiac Operations. Am J Cardiol 2018;
121:125.
23. Lee TH, Marcantonio ER, Mangione CM, et al. Derivation and prospective validation of a
simple index for prediction of cardiac risk of major noncardiac surgery. Circulation 1999;
100:1043.
24. Bilimoria KY, Liu Y, Paruch JL, et al. Development and evaluation of the universal ACS
NSQIP surgical risk calculator: a decision aid and informed consent tool for patients and
surgeons. J Am Coll Surg 2013; 217:833.
17 de 32 18/06/2020 11:50
25. Cohn SL, Subramanian S. Estimation of cardiac risk before noncardiac surgery: the
evolution of cardiac risk indices. Hosp Pract (1995) 2014; 42:46.
26. Goldman L, Caldera DL, Nussbaum SR, et al. Multifactorial index of cardiac risk in
noncardiac surgical procedures. N Engl J Med 1977; 297:845.
27. Detsky AS, Abrams HB, McLaughlin JR, et al. Predicting cardiac complications in patients
undergoing non-cardiac surgery. J Gen Intern Med 1986; 1:211.
28. Detsky AS, Abrams HB, Forbath N, et al. Cardiac assessment for patients undergoing
noncardiac surgery. A multifactorial clinical risk index. Arch Intern Med 1986; 146:2131.
29. Younis LT, Miller DD, Chaitman BR. Preoperative strategies to assess cardiac risk before
noncardiac surgery. Clin Cardiol 1995; 18:447.
30. Eagle KA, Coley CM, Newell JB, et al. Combining clinical and thallium data optimizes
preoperative assessment of cardiac risk before major vascular surgery. Ann Intern Med
1989; 110:859.
31. Vanzetto G, Machecourt J, Blendea D, et al. Additive value of thallium single-photon

emission computed tomography myocardial imaging for prediction of perioperative events
in clinically selected high cardiac risk patients having abdominal aortic surgery. Am J
Cardiol 1996; 77:143.
32. Paul SD, Eagle KA, Kuntz KM, et al. Concordance of preoperative clinical risk with
angiographic severity of coronary artery disease in patients undergoing vascular surgery.
Circulation 1996; 94:1561.
33. Vascular Events In Noncardiac Surgery Patients Cohort Evaluation (VISION) Study
Investigators, Devereaux PJ, Chan MT, et al. Association between postoperative troponin
levels and 30-day mortality among patients undergoing noncardiac surgery. JAMA 2012;
307:2295.
34. Devereaux PJ, Xavier D, Pogue J, et al. Characteristics and short-term prognosis of
perioperative myocardial infarction in patients undergoing noncardiac surgery: a cohort
study. Ann Intern Med 2011; 154:523.
35. Gupta PK, Gupta H, Sundaram A, et al. Development and validation of a risk calculator
for prediction of cardiac risk after surgery. Circulation 2011; 124:381.
36. Ford MK, Beattie WS, Wijeysundera DN. Systematic review: prediction of perioperative
cardiac complications and mortality by the revised cardiac risk index. Ann Intern Med
18 de 32 18/06/2020 11:50
2010; 152:26.
37. Devereaux PJ, Goldman L, Cook DJ, et al. Perioperative cardiac events in patients
undergoing noncardiac surgery: a review of the magnitude of the problem, the
pathophysiology of the events and methods to estimate and communicate risk. CMAJ
2005; 173:627.
38. POISE Study Group, Devereaux PJ, Yang H, et al. Effects of extended-release metoprolol
succinate in patients undergoing non-cardiac surgery (POISE trial): a randomised
controlled trial. Lancet 2008; 371:1839.
39. Davis C, Tait G, Carroll J, et al. The Revised Cardiac Risk Index in the new millennium: a
single-centre prospective cohort re-evaluation of the original variables in 9,519
consecutive elective surgical patients. Can J Anaesth 2013; 60:855.
40. Dakik HA, Chehab O, Eldirani M, et al. A New Index for Pre-Operative Cardiovascular
Evaluation. J Am Coll Cardiol 2019; 73:3067.
41. Bertges DJ, Goodney PP, Zhao Y, et al. The Vascular Study Group of New England
Cardiac Risk Index (VSG-CRI) predicts cardiac complications more accurately than the
Revised Cardiac Risk Index in vascular surgery patients. J Vasc Surg 2010; 52:674.
42. Bertges DJ, Neal D, Schanzer A, et al. The Vascular Quality Initiative Cardiac Risk Index
for prediction of myocardial infarction after vascular surgery. J Vasc Surg 2016; 64:1411.
43. QxMD. Estimate perioperative risk around the time of vascular surgery using Vascular Qu
ality Initiative risk calculators. https://qxmd.com/vascular-study-group-new-england-decisi
on-support-tools (Accessed on February 06, 2020).
44. Auerbach A, Goldman L. Assessing and reducing the cardiac risk of noncardiac surgery.
Circulation 2006; 113:1361.
45. Kertai MD, Boersma E, Bax JJ, et al. A meta-analysis comparing the prognostic accuracy
of six diagnostic tests for predicting perioperative cardiac risk in patients undergoing
major vascular surgery. Heart 2003; 89:1327.
46. Eagle KA, Singer DE, Brewster DC, et al. Dipyridamole-thallium scanning in patients
undergoing vascular surgery. Optimizing preoperative evaluation of cardiac risk. JAMA
1987; 257:2185.
47. Boucher CA, Brewster DC, Darling RC, et al. Determination of cardiac risk by
dipyridamole-thallium imaging before peripheral vascular surgery. N Engl J Med 1985;
19 de 32 18/06/2020 11:50
312:389.
48. Brown KA, Rowen M. Extent of jeopardized viable myocardium determined by myocardial
perfusion imaging best predicts perioperative cardiac events in patients undergoing
noncardiac surgery. J Am Coll Cardiol 1993; 21:325.
49. Younis L, Stratmann H, Takase B, et al. Preoperative clinical assessment and

dipyridamole thallium-201 scintigraphy for prediction and prevention of cardiac events in
patients having major noncardiovascular surgery and known or suspected coronary artery
disease. Am J Cardiol 1994; 74:311.
50. Stratmann HG, Younis LT, Wittry MD, et al. Dipyridamole technetium 99m sestamibi
myocardial tomography for preoperative cardiac risk stratification before major or minor
nonvascular surgery. Am Heart J 1996; 132:536.
51. Poldermans D, Arnese M, Fioretti PM, et al. Improved cardiac risk stratification in major
vascular surgery with dobutamine-atropine stress echocardiography. J Am Coll Cardiol
1995; 26:648.
52. Boersma E, Poldermans D, Bax JJ, et al. Predictors of cardiac events after major
vascular surgery: Role of clinical characteristics, dobutamine echocardiography, and beta-
blocker therapy. JAMA 2001; 285:1865.
53. Das MK, Pellikka PA, Mahoney DW, et al. Assessment of cardiac risk before nonvascular
surgery: dobutamine stress echocardiography in 530 patients. J Am Coll Cardiol 2000;
35:1647.
54. Young EL, Karthikesalingam A, Huddart S, et al. A systematic review of the role of
cardiopulmonary exercise testing in vascular surgery. Eur J Vasc Endovasc Surg 2012;
44:64.
55. Landesberg G, Mosseri M, Shatz V, et al. Cardiac troponin after major vascular surgery:
the role of perioperative ischemia, preoperative thallium scanning, and coronary
revascularization. J Am Coll Cardiol 2004; 44:569.
56. Labib SB, Goldstein M, Kinnunen PM, Schick EC. Cardiac events in patients with
negative maximal versus negative submaximal dobutamine echocardiograms undergoing
noncardiac surgery: importance of resting wall motion abnormalities. J Am Coll Cardiol
2004; 44:82.
57. Leppo J, Plaja J, Gionet M, et al. Noninvasive evaluation of cardiac risk before elective
vascular surgery. J Am Coll Cardiol 1987; 9:269.
20 de 32 18/06/2020 11:50
58. Carliner NH, Fisher ML, Plotnick GD, et al. Routine preoperative exercise testing in
patients undergoing major noncardiac surgery. Am J Cardiol 1985; 56:51.
59. Sgura FA, Kopecky SL, Grill JP, Gibbons RJ. Supine exercise capacity identifies patients
at low risk for perioperative cardiovascular events and predicts long-term survival. Am J
Med 2000; 108:334.
60. Junejo MA, Mason JM, Sheen AJ, et al. Cardiopulmonary exercise testing for
preoperative risk assessment before hepatic resection. Br J Surg 2012; 99:1097.
61. Morgan PB, Panomitros GE, Nelson AC, et al. Low utility of dobutamine stress
echocardiograms in the preoperative evaluation of patients scheduled for noncardiac
surgery. Anesth Analg 2002; 95:512.
62. Kontos MC, Brath LK, Akosah KO, Mohanty PK. Cardiac complications in noncardiac
surgery: relative value of resting two-dimensional echocardiography and dipyridamole
thallium imaging. Am Heart J 1996; 132:559.
63. Rohde LE, Polanczyk CA, Goldman L, et al. Usefulness of transthoracic

echocardiography as a tool for risk stratification of patients undergoing major noncardiac
surgery. Am J Cardiol 2001; 87:505.
64. Baron JF, Mundler O, Bertrand M, et al. Dipyridamole-thallium scintigraphy and gated
radionuclide angiography to assess cardiac risk before abdominal aortic surgery. N Engl J
Med 1994; 330:663.
65. Halm EA, Browner WS, Tubau JF, et al. Echocardiography for assessing cardiac risk in
patients having noncardiac surgery. Study of Perioperative Ischemia Research Group.
Ann Intern Med 1996; 125:433.
66. Flu WJ, van Kuijk JP, Hoeks SE, et al. Prognostic implications of asymptomatic left
ventricular dysfunction in patients undergoing vascular surgery. Anesthesiology 2010;
112:1316.
67. Raby KE, Goldman L, Creager MA, et al. Correlation between preoperative ischemia and
major cardiac events after peripheral vascular surgery. N Engl J Med 1989; 321:1296.
68. Mangano DT, Browner WS, Hollenberg M, et al. Association of perioperative myocardial
ischemia with cardiac morbidity and mortality in men undergoing noncardiac surgery. The
Study of Perioperative Ischemia Research Group. N Engl J Med 1990; 323:1781.
69. Park SJ, Choi JH, Cho SJ, et al. Comparison of transthoracic echocardiography with
21 de 32 18/06/2020 11:50
N-terminal pro-brain natriuretic Peptide as a tool for risk stratification of patients

undergoing major noncardiac surgery. Korean Circ J 2011; 41:505.
70. Rodseth RN, Biccard BM, Le Manach Y, et al. The prognostic value of pre-operative and
post-operative B-type natriuretic peptides in patients undergoing noncardiac surgery:
B-type natriuretic peptide and N-terminal fragment of pro-B-type natriuretic peptide: a
systematic review and individual patient data meta-analysis. J Am Coll Cardiol 2014;
63:170.
71. Duceppe E, Patel A, Chan MTV, et al. Preoperative N-Terminal Pro-B-Type Natriuretic
Peptide and Cardiovascular Events After Noncardiac Surgery: A Cohort Study. Ann Intern
Med 2020; 172:96.
72. Duceppe E, Parlow J, MacDonald P, et al. Canadian Cardiovascular Society Guidelines

on Perioperative Cardiac Risk Assessment and Management for Patients Who Undergo
Noncardiac Surgery. Can J Cardiol 2017; 33:17.
73. Fleisher LA. The Value of Preoperative Assessment Before Noncardiac Surgery in the
Era of Value-Based Care. Circulation 2017; 136:1769.
Topic 6616 Version 59.0
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GRAPHICS
Revised cardiac risk index (RCRI)
6 independent predictors of major cardiac complications [1]

High-risk type of surgery (examples include vascular surgery and any open intraperitoneal or intrathoracic
procedures)
History of ischemic heart disease (history of myocardial infarction or a positive exercise test, current
complaint of chest pain considered to be secondary to myocardial ischemia, use of nitrate therapy, or ECG
with pathological Q waves; do not count prior coronary revascularization procedure unless one of the other
criteria for ischemic heart disease is present)
History of heart failure
History of cerebrovascular disease
Diabetes mellitus requiring treatment with insulin
Preoperative serum creatinine >2.0 mg/dL (177 micromol/L)
Rate of cardiac death, nonfatal myocardial infarction, and nonfatal cardiac arrest
according to the number of predictors [2]
No risk factors – 0.4% (95% CI 0.1-0.8)
1 risk factor – 1.0% (95% CI 0.5-1.4)
2 risk factors – 2.4% (95% CI 1.3-3.5)
3 or more risk factors – 5.4% (95% CI 2.8-7.9)
Rate of myocardial infarction, pulmonary edema, ventricular fibrillation, primary

cardiac arrest, and complete heart block [1]
No risk factors – 0.5% (95% CI 0.2-1.1)
1 risk factor – 1.3% (95% CI 0.7-2.1)
2 risk factors – 3.6% (95% CI 2.1-5.6)
3 or more risk factors – 9.1% (95% CI 5.5-13.8)
ECG: electrocardiogram.
References:
1. Lee TH, Marcantonio ER, Mangione CM, et al. Derivation and prospective validation of a simple index for
prediction of cardiac risk of major noncardiac surgery. Circulation 1999; 100:1043.
2. Devereaux PJ, Goldman L, Cook DJ, et al. Perioperative cardiac events in patients undergoing noncardiac
surgery: A review of the magnitude of the problem, the pathophysiology of the events, and methods to
estimate and communicate risk. CMAJ 2005; 173:627.
Graphic 57075 Version 14.0
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Stepwise approach to perioperative cardiac assessment for CAD
ACS: acute coronary syndrome; CABG: coronary artery bypass graft surgery; CAD: coronary artery
disease; CPG: clinical practice guideline; DASI: Duke Activity Status Index; GDMT: guideline-directed
therapy; HF: heart failure; MACE: major adverse cardiac event; MET: metabolic equivalent; NB: no
benefit; NSQIP: National Surgical Quality Improvement Program; PCI: percutaneous coronary
intervention; RCRI: Revised Cardiac Risk Index; STEMI: ST elevation myocardial infarction;
UA/NSTEMI: unstable angina/non-ST elevation myocardial infarction; VHD: valvular heart disease.
Reproduced from: Fleisher LA, Fleischmann KE, Auerbach AD. 2014 ACC/AHA Guideline on Perioperative
Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery: A Report of the
American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll
Cardiol 2014. [Epub ahead of print]. Illustration used with the permission of Elsevier Inc. All rights
reserved.
24 de 32 18/06/2020 11:50
25 de 32 18/06/2020 11:50
Duke activity status index questionnaire to determine functional capacity [1]
Activity Weight
Can you...
1. Take care of yourself, that is, eating, dressing, bathing or using the toilet? 2.75
2. Walk indoors, such as around your house? 1.75
3. Walk a block or 2 on level ground? 2.75
4. Climb a flight of stairs or walk up a hill? 5.50
5. Run a short distance? 8.00
6. Do light work around the house like dusting or washing dishes? 2.70
7. Do moderate work around the house like vacuuming, sweeping floors, or carrying in groceries? 3.50
8. Do heavy work around the house like scrubbing floors, or lifting or moving heavy furniture? 8.00
9. Do yardwork like raking leaves, weeding or pushing a power mower? 4.50
10. Have sexual relations? 5.25
11. Participate in moderate recreational activities like golf, bowling, dancing, doubles tennis, or 6.00
throwing a baseball or football?
12. Participate in strenuous sports like swimming, singles tennis, football, basketball or skiing? 7.50
Total DASI score: ______

METs [(DASI score × 0.43) + 9.6] / 3.5: ______
The higher the DASI score, the more physically active the patient is. Patients who can achieve <4 METs have
poor functional capacity, 4 to 10 METs suggest moderate functional capacity, and >10 METs suggest excellent
functional capacity.
DASI: Duke activity status index; METs: metabolic equivalents.
Reference:
1. Hlatky MA, Boineau RE, Higginbotham MB, et al. A brief self-administered questionnaire to determine functional
capacity (the Duke Activity Status Index). Am J Cardiol 1989; 64:651.
Reproduced with permission from: Duke University. Copyright © 1989 Duke University. All rights reserved.
26 de 32 18/06/2020 11:50
Selected examples of low, intermediate, and high intrinsic cardiac risk

operations
Estimated
cardiac risk of
Description Odds ratio* (95% CI)
hypothetical
patient ¶ (%)
Low intrinsic cardiac risk
Partial mastectomy (lumpectomy) 0.22 (0.15-0.31) 0.05
Arthroscopic rotator cuff repair 0.32 (0.19-0.54) 0.07
Simple mastectomy (complete breast) 0.37 (0.26-0.50) 0.08
Laparoscopic appendectomy 0.45 (0.33-0.62) 0.10
Laparoscopic cholecystectomy 0.62 (0.53-0.72) 0.14
Intermediate intrinsic cardiac risk
Transurethral resection of bladder tumor, large 0.85 (0.61-1.20) 0.19
Laparoscopic prostatectomy 0.88 (0.69-1.12) 0.19
Open appendectomy 0.95 (0.51-1.75) 0.21
Total hip arthroplasty 0.95 (0.83-1.08) 0.21
Laparoscopic radial hysterectomy with bilateral 1.05 (0.57-1.94) 0.23

salpingo-oophorectomy
High intrinsic cardiac risk
Laparoscopic total abdominal colectomy with 1.50 (0.92-2.44) 0.33

ileostomy
Breast reconstruction with free flap 1.52 (0.81-2.86) 0.33
Open cholecystectomy 1.55 (1.25-1.92) 0.34
Open ventral hernia repair, incarcerated or 1.78 (1.29-2.44) 0.39

strangulated, recurrent
Whipple procedure, pylorus-sparing 4.70 (4.00-5.53) 1.02
ASA: American Society of Anesthesiologists.

* Odds ratios are relative to the statistically estimated average procedure. Values greater than 1.0 represent higher
than average risk for perioperative adverse cardiac events, whereas values less than 1.0 represent lower than
average risk for perioperative adverse cardiac events.
¶ The hypothetical patient used to estimate numerical risk values across all operations for comparison was a 67-year-
old white female with hypertension, diabetes requiring oral therapy, and a body mass index of 32 (class I obesity),
who is functionally independent, does not smoke, and is of ASA physical class II.
From: Liu JB, Liu Y, Cohen ME, et al. Defining the intrinsic cardiac risks of operations to improve preoperative cardiac
risk assessments. Anesthesiology 2018; 128:283. DOI: 10.1097/ALN.0000000000002024. Copyright © 2018
American Society of Anesthesiologists. Reproduced with permission from Wolters Kluwer Health. Unauthorized
reproduction of this material is prohibited.
27 de 32 18/06/2020 11:50
ACC/AHA guideline summary: Cardiac risk stratification for noncardiac

surgical procedures
High risk (reported risk of cardiac death or nonfatal myocardial infarction [MI]
often greater than 5%)
Aortic and other major vascular surgery
Peripheral artery surgery
Intermediate risk (reported risk of cardiac death or nonfatal MI generally 1 to 5%)
Carotid endarterectomy
Head and neck surgery
Intraperitoneal and intrathoracic surgery
Orthopedic surgery
Prostate surgery
Low risk* (reported risk of cardiac death or nonfatal MI generally less than 1%)
Ambulatory surgery ¶
Endoscopic procedures
Superficial procedures
Cataract surgery
Breast surgery
* Do not generally require further preoperative cardiac testing.

¶ Ambulatory surgery refers to surgery in patients who are admitted on the day of an operation or procedure, and
return home on the same day.
Data from: Fleisher LA, Beckman JA, Brown KA, et al. ACC/AHA 2007 guidelines on perioperative cardiovascular
evaluation and care for noncardiac surgery: a report of the American College of Cardiology/American Heart
Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines on Perioperative
Cardiovascular Evaluation for Noncardiac Surgery) developed in collaboration with the American Society of
Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society of Cardiovascular
Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and
Biology, and Society for Vascular Surgery. J Am Coll Cardiol 2007; 50:e159.
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Rates of adverse cardiac outcomes from noncardiac surgery
Number Davis 6 Davis 5

Lee Lee
of risk Devereaux* Lindenauer ¶ factor factor
derivation validation
factors RCRI RCRI
0 0.5% 0.4% 0.4% 1.4% 0.5% 0.5%
1 1.3% 0.9% 1% 2.2% 2.6% 2.9%
2 3.6% 6.6% 2.4% 3.9% 7.2% 7.4%
3 or more 9.1% 11% 5.4% 5.8 to 7.4% 14.4% 17%
RCRI: Revised cardiac risk index.

* Excluded pulmonary edema and complete heart block.
¶ Hospital mortality only.
1. 1. Devereaux PJ, Goldman L, Cook DJ, et al. Perioperative cardiac events in patients undergoing noncardiac
surgery: a review of the magnitude of the problem, the pathophysiology of the events and methods to
estimate and communicate risk. CMAJ 2005; 173:627.
2. 2. Lindenauer PK, Pekow P, Wang K, et al. Perioperative beta-blocker therapy and mortality after major
noncardiac surgery. N Engl J Med 2005; 353:349.
3. 3. Davis C, Tait G, Carroll J, et al. The Revised Cardiac Risk Index in the new millennium: a single-centre
prospective cohort re-evaluation of the original variables in 9,519 consecutive elective surgical patients. Can J
Anaesth 2013; 60:855.
29 de 32 18/06/2020 11:50
American Society of Anesthesiologists (ASA) Physical Status Classification

System
ASA PS Examples, including, but not

Definition
classification limited to:
ASA I A normal healthy patient. Healthy, non-smoking, no or minimal

alcohol use.
ASA II A patient with mild systemic disease. Mild diseases only without substantive
functional limitations. Current smoker,
social alcohol drinker, pregnancy, obesity
(30<BMI<40), well-controlled DM/HTN,
mild lung disease.
ASA III A patient with severe systemic disease. Substantive functional limitations; one or
more moderate to severe diseases. Poorly
controlled DM or HTN, COPD, morbid
obesity (BMI ≥40), active hepatitis, alcohol
dependence or abuse, implanted
pacemaker, moderate reduction of ejection
fraction, ESRD undergoing regularly
scheduled dialysis, premature infant
PCA<60 weeks, history (>3 months) of MI,
CVA, TIA, or CAD/stents.
ASA IV A patient with severe systemic disease that Recent (<3 months) MI, CVA, TIA, or
is a constant threat to life. CAD/stents, ongoing cardiac ischemia or
severe valve dysfunction, severe reduction
of ejection fraction, sepsis, DIC, ARDS, or
ESRD not undergoing regularly scheduled
dialysis.
ASA V A moribund patient who is not expected to Ruptured abdominal/thoracic aneurysm,

survive without the operation. massive trauma, intracranial bleed with
mass effect, ischemic bowel in the face of
significant cardiac pathology or multiple
organ/system dysfunction.
ASA VI A declared brain-dead patient whose

organs are being removed for donor
purposes.
The addition of "E" to the numerical status (eg, IE, IIE, etc.) denotes Emergency surgery (an emergency is
defined as existing when delay in treatment of the patient would lead to a significant increase in the threat to
life or body part).
BMI: body mass index; DM: diabetes mellitus; HTN: hypertension; COPD: chronic obstructive pulmonary disease;
ESRD: end-stage renal disease; PCA: post conceptual age; MI: myocardial infarction; CVA: cerebrovascular accident;
TIA: transient ischemic attack; CAD: coronary artery disease; DIC: disseminated intravascular coagulation; ARDS:
acute respiratory distress syndrome.
ASA Physical Status Classification System (Copyright © 2014) is reprinted with permission of the American Society of
Anesthesiologists, 1061 American Lane, Schaumburg, Illinois 60173-4973.
30 de 32 18/06/2020 11:50
Incidence of major cardiac complications increases with the

number of risk factors
Among 4513 patients, the incidence of a major cardiac complication increases with a higher
cardiac risk index (1 to 4), which is based upon six independent predictors, including high-
risk type of surgery, history of ischemic heart disease, history of heart failure, history of
cerebrovascular disease, preoperative treatment with insulin, and preoperative serum
creatinine >2.0 mg/dL (177 mol/L). By definition, patients undergoing abdominal aortic
aneurysm (AAA), thoracic, and abdominal procedures were excluded from class I. In all
subsets, except patients undergoing AAA, there was a statistically significant trend toward
greater risk with higher risk class.
Data from Lee TH, Marcantonio ER, Mangione CM, et al. Circulation 1999; 100:1043.
31 de 32 18/06/2020 11:50
Contributor Disclosures
Steven L Cohn, MD, MACP, SFHM Nothing to disclose Lee A Fleisher, MD Nothing to
disclose Patricia A Pellikka, MD, FACC, FAHA, FASE Grant/Research/Clinical Trial Support: GE
Healthcare [cardiac ultrasound equipment] and OxThera [therapy for primary hyperoxaluria].
Consultant/Advisory Boards: Bracco Diagnostics, Inc [echocardiography image enhancing agent]. Jane
Givens, MD Consultant/Advisory Boards (Partner): CVS Health/CVS Omnicare [Pharmaceutical
management of formulary decision-making]. Gordon M Saperia, MD Nothing to disclose
Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are
addressed by vetting through a multi-level review process, and through requirements for references to be
provided to support the content. Appropriately referenced content is required of all authors and must
conform to UpToDate standards of evidence.
Conflict of interest policy
32 de 32 18/06/2020 11:50

Evaluation of Cardiac Risk Prior To Noncardiac Surgery - UpToDate

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The incidence of an adverse cardiovascular outcome is related to the baseline risk.

● Physiologic factors associated with surgery predisposed to myocardial ischemia, which is

INITIAL PREOPERATIVE EVALUATION

Similar to recommendations made in the 2014 American College of Cardiology/American Heart

Anesthesiology (ESC/ESA) guidelines on noncardiac surgery, we obtain an electrocardiogram

Functional status/capacity — Cardiac functional status or capacity, as determined by doctors

Functional status can be expressed in metabolic equivalents (1 MET is defined as 3.5 mL O2

noncardiac surgery", section on 'Surgical risk'.)

● History of ischemic heart disease (RCRI).

● History of heart failure (RCRI).

● History of cerebrovascular disease (RCRI).

● Insulin dependent diabetes mellitus (RCRI).

● Preoperative serum creatinine ≥2.0 mg/dL (RCRI) or >1.5 mg/dL (NSQIP).

● Increasing age (NQSIP).

● American Society of Anesthesiologist class (NSQIP).

● Preoperative functional status (NSQIP). (See 'Functional status/capacity' above.)

● Atrial fibrillation – A retrospective, administrative database study demonstrated an

● No risk factors – 0.4 percent

● In a large retrospective analysis on mortality, the perioperative risk was evaluated in

● RCRI only included in-patient complications, not 30-day event rates.

decreasing while type 2, hemodynamic MI is increasing.

AUB-POCES index — The 2019 American University of Beirut-Pre-Operative Cardiovascular

NSQIP universal surgical risk calculator — Based on 1,414,006 patients encompassing

MANAGEMENT BASED ON RISK

FURTHER CARDIAC TESTING

Resting echocardiography — Resting echocardiography is not indicated in the perioperative

24-hour ambulatory monitoring — As with echocardiography and stress testing, we do not

compared with RCRI alone.

Our approach to the evaluation of patients scheduled to undergo noncardiac surgery is

SOCIETY GUIDELINE LINKS

SUMMARY AND RECOMMENDATIONS

● We obtain an electrocardiogram (ECG) in patients with cardiac disease (except in those

Use of UpToDate is subject to the Subscription and License Agreement.

1. Mangano DT, Goldman L. Preoperative assessment of patients with known or suspected

3. Smilowitz NR, Gupta N, Ramakrishna H, et al. Perioperative Major Adverse

peripheral arterial disease. N Engl J Med 1992; 326:381.

7. Stampfer MJ, Grodstein F, Bechtel S. Postmenopausal estrogen and cardiovascular

noncardiac surgery: a report of the American College of Cardiology/American Heart

31. Vanzetto G, Machecourt J, Blendea D, et al. Additive value of thallium single-photon

49. Younis L, Stratmann H, Takase B, et al. Preoperative clinical assessment and

63. Rohde LE, Polanczyk CA, Goldman L, et al. Usefulness of transthoracic

N-terminal pro-brain natriuretic Peptide as a tool for risk stratification of patients

72. Duceppe E, Parlow J, MacDonald P, et al. Canadian Cardiovascular Society Guidelines

Topic 6616 Version 59.0

Revised cardiac risk index (RCRI)

6 independent predictors of major cardiac complications [1]

History of heart failure

History of cerebrovascular disease

Diabetes mellitus requiring treatment with insulin

Preoperative serum creatinine >2.0 mg/dL (177 micromol/L)

1 risk factor – 1.0% (95% CI 0.5-1.4)

2 risk factors – 2.4% (95% CI 1.3-3.5)

3 or more risk factors – 5.4% (95% CI 2.8-7.9)

Rate of myocardial infarction, pulmonary edema, ventricular fibrillation, primary

1 risk factor – 1.3% (95% CI 0.7-2.1)

2 risk factors – 3.6% (95% CI 2.1-5.6)

3 or more risk factors – 9.1% (95% CI 5.5-13.8)

Graphic 57075 Version 14.0

Stepwise approach to perioperative cardiac assessment for CAD

Graphic 96563 Version 3.0