Cardiovascular Risk
Perioperative cardiovascular assessment combines the patient's disease, symptoms and functional reserve with the proposed operation and its urgency. A procedure name alone does not establish an individual's risk: a brief cystoscopy and a prolonged bowel-based reconstruction require different plans, and a minimally invasive approach does not eliminate cardiac risk. The purpose of assessment is to identify instability, estimate risk, optimize treatment and plan monitoring—not to obtain a generic “cardiac clearance.”[1]
This workflow uses the 2024 AHA/ACC multisociety perioperative guideline, with subsequent major trials and the 2026 Universal Definition of Myocardial Infarction noted below. See Risk Calculators, Frailty and Antithrombotic Therapy for their dedicated workflows.
Stepwise Approach (2024 AHA/ACC)
- Establish urgency and the consequence of delay. Emergency surgery requires concurrent stabilization and a proportionate assessment; a risk score must not become an avoidable delay. Time-sensitive cancer or reconstructive surgery needs a shared decision about the competing risks of waiting.
- Identify unstable disease. Acute coronary syndrome, decompensated heart failure and unstable arrhythmias generally require evaluation and treatment before elective surgery. Severe valve disease, pulmonary hypertension and obstructive hypertrophic cardiomyopathy require specific assessment rather than a blanket score-based decision.
- Estimate combined patient and surgical risk, using a validated tool when appropriate.
- Assess functional capacity and relevant frailty, along with symptoms, examination and prior records.
- Order additional tests only when their results can change care. Consider a different operation, optimization, further cardiac evaluation or planned postoperative monitoring when risk is elevated.[1]
Surgical Risk Categories
The AHA/ACC decision pathway distinguishes low predicted cardiovascular risk (<1%) from elevated risk (≥1%). Apply this to the combination of patient and procedure. Do not label every GU operation “intermediate risk,” or assume every endoscopic operation is low risk regardless of the patient's condition.[1]
For complex pelvic or upper-tract reconstruction, specify the expected duration, blood loss, bowel involvement, position, pneumoperitoneum, potential fluid shifts and postoperative resources. These details make the anesthesia/cardiology discussion more useful than the specialty label alone.
Risk Calculators
| Tool | What it contributes | Important boundary |
|---|---|---|
| RCRI | Six clinical/procedural predictors of major cardiac complications | Its original outcome and validation population differ from newer 30-day death/MI/cardiac-arrest composites; do not attach one universal event percentage to each score |
| Gupta NSQIP MICA | Age, ASA class, functional dependence, creatinine and surgical category predict MI/cardiac arrest | Uses broad procedure categories, not the same CPT-specific model as the universal calculator |
| ACS NSQIP Surgical Risk Calculator | Procedure-specific estimates based on CPT and patient characteristics | Check the selected operation, outcome and current model; estimates do not capture every reconstructive complexity |
The guideline does not establish one calculator as best for all patients. Record which model and outcome were used. Frailty, severe valve disease, pulmonary hypertension, recent stroke and implanted devices may require additional planning even when incompletely represented by the score.[1]
Functional Capacity
For elevated-risk surgery, a structured instrument such as the Duke Activity Status Index (DASI) is reasonable. Poor capacity is conventionally <4 METs or DASI ≤34 in the guideline's testing pathway. Ask what limits activity: dyspnea or angina has a different implication from joint disease or mobility impairment.[1]
Good capacity and stable symptoms usually argue against routine ischemia testing. Excellent self-reported exercise tolerance does not override new chest pain, decompensated heart failure or other active disease. Frailty assessment is useful in adults aged ≥65, and younger adults perceived to be frail, when elevated-risk surgery is planned; see the frailty workflow.
Preoperative Cardiac Testing
| Test | When it can help | Avoid |
|---|---|---|
| 12-lead ECG | Known coronary disease, significant arrhythmia, peripheral/cerebrovascular or structural heart disease, or cardiovascular symptoms and elevated-risk surgery; it may also be considered in asymptomatic patients undergoing elevated-risk surgery | Routine ECG for an asymptomatic patient undergoing low-risk surgery; treating an isolated tracing as a complete assessment |
| Echocardiography / LV function | New dyspnea, examination evidence of heart failure or suspected new/worsening ventricular dysfunction; known HF with worsening symptoms; assessment of relevant suspected valve disease | Routine repeat LV-function assessment in an asymptomatic, clinically stable patient |
| Stress testing | May be considered when surgery and calculated cardiovascular risk are elevated, capacity is poor/unknown, and identifying high-risk ischemia would change management | Automatic testing solely because the patient is older, has a positive RCRI or cannot exercise; routine testing with stable adequate capacity or low-risk surgery |
| Coronary CT angiography | An alternative in selected patients with elevated risk and poor/unknown capacity when identifying high-risk coronary anatomy would change care | Routine screening before low-risk surgery |
New ECG abnormalities warrant consideration of further evaluation. Coronary angiography is not a routine preoperative test. Revascularize for appropriate cardiac indications: acute coronary syndrome and selected significant left-main disease are different from prophylactic revascularization of stable non–left-main disease solely to enable surgery.[1]
Preoperative Biomarkers
In patients undergoing elevated-risk surgery who have known CVD, age ≥65, or age ≥45 with symptoms suggestive of CVD, preoperative BNP/NT-proBNP measurement is reasonable; cardiac troponin measurement may also be reasonable. These are combined criteria, not independent indications to test every older patient before a minor procedure.[1]
An abnormal result prompts interpretation in context—including renal function, heart failure and prior values—and a discussion about further assessment and monitoring. It is not an automatic cancellation threshold. If postoperative troponin surveillance is planned, obtain a preoperative value to help distinguish chronic elevation from acute injury, as emphasized by the 2026 Universal Definition.[6]
Perioperative Medical Therapy
| Therapy | Practical plan |
|---|---|
| Statin | Continue established treatment. Start when there is an ordinary long-term indication, with intent to continue afterward; routine perioperative loading for all patients is not established |
| Beta-blocker | Continue stable chronic treatment as clinically appropriate. If a new independent indication exists, begin sufficiently in advance—optimally more than 7 days—to assess tolerance and titrate. Do not start on the day of surgery solely for prophylaxis |
| ACE inhibitor / ARB | In selected patients taking these for controlled hypertension who face elevated-risk surgery, omitting them 24 hours beforehand may reduce intraoperative hypotension. In HFrEF, continuation is reasonable unless contraindicated. Write an individualized plan and restart when blood pressure, renal function and oral intake permit |
| Other HF treatment | Continue guideline-directed therapy for compensated HF when appropriate, with the SGLT2 exception below; avoid unnecessary interruption and reassess with decompensation |
| SGLT2 inhibitor | Withhold canagliflozin, dapagliflozin or empagliflozin for at least 3 days, and ertugliflozin for at least 4 days, before scheduled surgery. Consider euglycemic ketoacidosis if perioperative illness produces acidosis despite a modest glucose level |
| Aspirin / anticoagulation | Balance the actual indication and thrombotic risk against procedural bleeding. Do not initiate aspirin routinely for perioperative cardiac protection or bridge every patient with AF; use the dedicated antithrombotic plan |
These recommendations require adjustment for hypotension, bradycardia, AKI and other contraindications. Avoid abrupt withdrawal of chronic beta-blockers or clonidine.[1]
Stop-or-Not (2024): among 2,222 randomized patients undergoing major noncardiac surgery, stopping renin–angiotensin-system inhibitors 48 hours before surgery versus continuing them produced similar observed 28-day death/major-complication rates (245/1,115 versus 247/1,107; about 22% in each group). Continuation caused more intraoperative hypotension. This superiority trial did not prove equivalence, and only 6% had heart failure; it does not establish a universal stop rule for HFrEF.[2]
Coronary Stents and Elective Surgery
Obtain the PCI date, indication, stent details and current antiplatelet regimen. The following timing guidance particularly concerns operations requiring antiplatelet interruption:[1]
| Situation | Guideline timing consideration |
|---|---|
| Balloon angioplasty without stent | Delay elective surgery at least 14 days |
| DES placed for acute coronary syndrome | Ideally delay elective surgery requiring interruption at least 12 months |
| DES placed for chronic coronary disease | Delay at least 6 months when feasible |
| Time-sensitive surgery after DES | May be considered at ≥3 months when the harm from delay outweighs perioperative cardiac risk |
| Any coronary stent placed within 30 days | Elective surgery requiring interruption of one or more antiplatelet agents is potentially harmful |
Continue aspirin 75–100 mg after PCI when possible, balancing bleeding and thrombotic risks. For time-sensitive surgery within 30 days of BMS or 3 months of DES, continue DAPT unless bleeding risk outweighs prevention of stent thrombosis. Decisions inside these windows need the treating cardiology and surgical teams; GU bleeding risk can matter even when bleeding is not intracranial. See Antithrombotic Therapy for interruption/restart details.
Valvular Heart Disease
Severe aortic stenosis requires evaluation for valve intervention before elective surgery, especially when symptomatic. Low-flow/low-gradient disease must not be excluded merely because a velocity or gradient threshold is absent. The guideline permits low-risk surgery in selected asymptomatic patients with moderate/severe AS and normal LV function documented within the preceding year; that statement does not automatically authorize a major bowel-based reconstruction.[1]
Other significant valve lesions, pulmonary hypertension and obstructive HCM need individualized anesthesia and specialist planning. Likewise, after a recent stroke/TIA, delaying elective noncardiac surgery for at least 3 months is reasonable under the 2024 guideline, with timing balanced against the surgical indication.
Cardiac Implantable Electronic Devices (CIEDs)
Confirm device type, generator location, pacing dependence, recent device assessment and the specific device's magnet response. Agree on a plan for anticipated electromagnetic interference (EMI), monitoring, external pacing/defibrillation and restoration of settings.[1]
- Monopolar electrosurgery and the current path matter. Interference risk is generally lower below the umbilicus with a pectoral transvenous device and an appropriate return-electrode position. Underbody return electrodes or unusual generator locations can change that assessment. Bipolar energy reduces risk when suitable.
- A pacemaker magnet is not a universal solution. Response may be programmable or absent, particularly with some leadless devices. Pacing-dependent patients facing relevant EMI may need programmed asynchronous pacing.
- An ICD magnet suspends tachyarrhythmia therapy; it does not provide asynchronous pacing. A pacing-dependent ICD patient may therefore require reprogramming rather than magnet placement alone.
- Maintain appropriate monitoring and rescue capability while therapy is disabled. Restore required settings before an unmonitored setting or discharge.
HoLEP uses laser energy; it should not be described as monopolar TURP. Plan around the actual energy devices used, including any electrosurgical hemostasis, rather than applying one rule to all endourology.
Blood Pressure and Hemodynamic Management
Assess an elevated preoperative reading in context. For elective elevated-risk surgery in patients with cardiovascular risk factors and a recent history of poorly controlled SBP ≥180 or DBP ≥110 mmHg, deferral may be considered; a single anxiety-associated reading is not an automatic cancellation rule. During surgery the guideline recommends maintaining MAP ≥60–65 mmHg or SBP ≥90 mmHg and treating postoperative hypotension below these ranges. Investigate the cause—bleeding, vasodilation, inadequate preload, arrhythmia or cardiac dysfunction—rather than treating the monitor alone.[1]
Major 2025 trials do not establish a benefit from routinely targeting higher pressures:
- IMPROVE-multi: 1,142 randomized and 1,134 analyzed high-risk abdominal-surgery patients; individualized nighttime-MAP targets versus MAP ≥65 gave 7-day AKI/myocardial-injury/arrest/death rates of 190/567 versus 173/567 (RR 1.10, 95% CI 0.93–1.30). Nephrectomy and kidney transplant were excluded.[3]
- PRETREAT: 3,522 randomized, 3,247 in the treated analysis population; risk-stratified targets of 70/80/90 versus usual care did not improve 6-month WHODAS disability (difference −0.5 points, 95% credible interval −1.9 to 0.9). It stopped for futility, and 29% lacked the primary follow-up outcome.[4]
These trials compared higher targets with actively managed usual care. They do not establish that profound/prolonged hypotension is safe, or remove the need for individualized management in a patient with compromised perfusion.
Myocardial Injury After Noncardiac Surgery (MINS)
MINS is acute postoperative troponin elevation above the assay’s 99th-percentile upper reference limit attributed to a presumed ischemic mechanism, occurring within 30 days, without requiring ischemic symptoms. It is distinct from chronic troponin elevation and from injury with an overt nonischemic cause such as pulmonary embolism or sepsis. An isolated elevated troponin does not establish myocardial infarction.[5]
The 2024 guideline says troponin surveillance at 24 and 48 hours may be reasonable for elevated-risk surgery in patients with known CVD, cardiovascular symptoms, or age ≥65 with cardiovascular risk factors. Routine surveillance is not indicated after low-risk surgery without concerning symptoms or signs.[1]
The 2026 Universal Definition emphasizes a preoperative baseline when surveillance is planned, an ECG when acute injury or clinical deterioration is detected, and appropriate coronary/cardiac imaging to establish the mechanism and confirm or exclude infarction. ST elevation or instability requires urgent assessment, not delayed outpatient follow-up.[6]
For detected injury, assess symptoms, ECG and serial troponin, review hemodynamics, anemia and competing causes, and involve the relevant acute-care/cardiology team. Optimize cardiovascular risk factors and arrange follow-up after stabilization. Antithrombotic treatment may be considered in selected MINS patients, balancing surgical bleeding; there is no universal aspirin–statin–ACE inhibitor–beta-blocker bundle for every troponin rise.[1]
References
1. Thompson A, Fleischmann KE, Smilowitz NR, et al. 2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM Guideline for Perioperative Cardiovascular Management for Noncardiac Surgery. J Am Coll Cardiol. 2024;84(19):1869–1969. doi:10.1016/j.jacc.2024.06.013
2. Legrand M, Falcone J, Cholley B, et al. Continuation vs Discontinuation of Renin-Angiotensin System Inhibitors Before Major Noncardiac Surgery: The Stop-or-Not Randomized Clinical Trial. JAMA. 2024;332(12):970–978. doi:10.1001/jama.2024.17123
3. Saugel B, Meidert AS, Brunkhorst FM, et al. Individualized Perioperative Blood Pressure Management in Patients Undergoing Major Abdominal Surgery: The IMPROVE-multi Randomized Clinical Trial. JAMA. 2025;334(21):1893–1904. doi:10.1001/jama.2025.17235
4. Kant M, van Klei WA, Hollmann MW, et al. Proactive vs Reactive Treatment of Hypotension During Surgery: The PRETREAT Randomized Clinical Trial. JAMA. 2025;334(21):1905–1914. doi:10.1001/jama.2025.18007
5. Ruetzler K, Smilowitz NR, Berger JS, et al. Diagnosis and Management of Patients With Myocardial Injury After Noncardiac Surgery: A Scientific Statement From the American Heart Association. Circulation. 2021;144(19):e287–e305. doi:10.1161/CIR.0000000000001024
6. Mills NL, Newby LK, Zaman S, et al. Fifth Universal Definition of Myocardial Infarction (2026). JACC. Published online August 27, 2026. doi:10.1016/j.jacc.2026.07.025