Cardiovascular Risk
Perioperative cardiovascular assessment combines the patient's disease, symptoms and functional reserve with the proposed operation and its urgency. A brief cystoscopy and a prolonged bowel-based reconstruction require different cardiovascular plans; a minimally invasive approach still carries cardiac risk. The purpose of assessment is to identify instability, estimate risk, optimize treatment and plan monitoring, and not to obtain a generic “cardiac clearance.”[1]
This workflow uses the reaffirmed 2026 AHA/ACC multisociety perioperative guideline, which replaces the 2024 publication without changing its recommendations or supporting text. Subsequent major trials and the 2026 Universal Definition of Myocardial Infarction are noted below.[15] The 2022 ESC non-cardiac surgery guideline and the 2017 Canadian Cardiovascular Society (CCS) guideline differ mainly in their emphasis on biomarkers (see Other Guideline Frameworks).[7][8] 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.
- 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.[1]
For complex pelvic or upper-tract reconstruction, specify the expected duration, blood loss, bowel involvement, position, pneumoperitoneum, potential fluid shifts and postoperative resources.
Risk Calculators
| Tool | What it contributes | Important boundary |
|---|---|---|
| RCRI | One point each for high-risk surgery (intraperitoneal, intrathoracic, suprainguinal vascular), ischemic heart disease, heart failure, cerebrovascular disease, insulin treatment and creatinine >2.0 mg/dL | Derived in 2,893 and prospectively validated in 1,422 of 4,315 patients aged ≥50 having elective major surgery; discrimination is moderate (pooled AUC 0.75 for mixed surgery, 0.64 after vascular surgery).[9][11] |
| 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[1] |
| ACS NSQIP Surgical Risk Calculator | Procedure-specific estimates based on CPT and patient characteristics | Check the selected operation, outcome and current model |
Major cardiac complication rates by RCRI score (0, 1, 2, ≥3) were 0.4%, 0.9%, 7% and 11% in the original validation cohort, and 0.5%, 2.6%, 7.2% and 14.4% in a 9,519-patient contemporary cohort in which insulin use and creatinine did not independently predict events.[9][10][11] Cystectomy, bowel-based reconstruction and other intraperitoneal operations already score the high-risk-surgery point.
Calculator choice depends on the patient and the outcome assessed. 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]
In practice, ask whether the patient can climb two flights of stairs or walk four blocks briskly without stopping. 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. Abnormal values are conventionally BNP >92 ng/L or NT-proBNP ≥300 ng/L; troponin is abnormal above the assay's 99th percentile.[1]
An abnormal result prompts interpretation in context (including renal function, heart failure and prior values) and a discussion about further assessment and monitoring. 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[1] |
| 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: in POISE (8,351 patients), extended-release metoprolol started 2–4 hours before surgery reduced MI (4.2% vs 5.7%) but increased death (3.1% vs 2.3%) and stroke (1.0% vs 0.5%)[12] |
| 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[1] |
| 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. Consider resumption once clinically stable and eating a normal diet.[1] |
| Aspirin / anticoagulation | Balance the actual indication and thrombotic risk against procedural bleeding. Do not initiate aspirin routinely for perioperative cardiac protection: in POISE-2 (10,010 patients), the 30-day composite of death or nonfatal MI occurred in 7.0% with aspirin versus 7.1% with placebo, while major bleeding was more frequent with aspirin (4.6% versus 3.8%).[13] Do not 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 or 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.[2]
Coronary Stents and Elective Surgery
Obtain the PCI date, indication, stent details and current antithrombotic regimen. For patients with prior PCI taking oral anticoagulant monotherapy that must be interrupted, substitute aspirin perioperatively when feasible until anticoagulation resumes (Class 1, B-NR).[1] The DES timing guidance below applies when surgery requires interruption of at least one antiplatelet agent:[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.[1] For time-sensitive surgery within 30 days of BMS or 3 months of DES, continue DAPT unless bleeding risk outweighs prevention of stent thrombosis. In select patients at high thrombotic risk whose surgery cannot be deferred <6 months after DES or <30 days after BMS, IV antiplatelet bridging may be considered (Class 2b, B-NR) after weighing procedural bleeding risk.[1] See Antithrombotic Therapy for interruption and 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.[1] The guideline permits low-risk surgery in selected asymptomatic patients with moderate or severe AS and normal LV function documented within the preceding year.[1]
Other significant valve lesions, pulmonary hypertension and obstructive HCM need individualized anesthesia and specialist planning. Likewise, after a recent stroke or TIA, delaying elective noncardiac surgery for at least 3 months is reasonable under the 2024 guideline, with timing balanced against the surgical indication (COR 2a, B-NR).[1]
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 or 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 can create EMI even below the umbilicus, and unusual generator locations can change that assessment; plan magnet use or device reprogramming when EMI is anticipated.[1] Bipolar energy reduces risk when suitable.
- Pacemaker magnets. Magnet response may be programmable or absent, particularly with some leadless devices. Pacemaker-dependent patients with transvenous pacemakers facing anticipated EMI above the umbilicus require asynchronous pacing by reprogramming or a magnet with a confirmed response (Class 1, B-NR); pacemaker-dependent patients with leadless devices require reprogramming to asynchronous mode (Class 1, C-LD).[1]
- An ICD magnet suspends tachyarrhythmia therapy; it does not provide asynchronous pacing. A pacing-dependent patient with a transvenous ICD facing anticipated EMI above the umbilicus requires reprogramming to asynchronous pacing with tachytherapies disabled (Class 1, B-NR).[1]
- Maintain appropriate monitoring and rescue capability while therapy is disabled. Restore required settings before an unmonitored setting or discharge.
HoLEP uses laser energy. Plan around the actual energy devices used, including any electrosurgical hemostasis.
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.[1] Investigate the cause (bleeding, vasodilation, inadequate preload, arrhythmia or cardiac dysfunction).[1]
Two 2025 trials found no clear benefit from routine higher pressure targets:
- 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 or 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.
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]
MINS is common and mostly silent. In VISION (15,065 patients aged ≥45), 8.0% had MINS by troponin T and only 15.8% of those had an ischemic symptom; MINS independently predicted 30-day mortality (adjusted HR 3.87).[14] With systematic troponin surveillance, the AHA statement cites about 20% after major inpatient surgery.[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]
When surveillance is planned, obtain a preoperative baseline. When acute injury or clinical deterioration is detected, obtain an ECG and, as needed, cardiac imaging to establish the mechanism and confirm or exclude infarction. ST elevation or instability requires urgent assessment, not delayed outpatient follow-up. The 2026 Universal Definition adopts sex-specific 99th-percentile limits to define myocardial injury, so interpret values against the assay-specific and sex-specific limit.[6]
For detected injury, assess symptoms, ECG and serial troponin, review hemodynamics, anemia and competing causes, and involve the relevant acute-care or cardiology team. Optimize cardiovascular risk factors and arrange follow-up after stabilization. Antithrombotic treatment may be considered in selected MINS patients after weighing surgical bleeding; no aspirin–statin–ACE inhibitor–beta-blocker bundle applies to every troponin rise.[1]
New-Onset Perioperative Atrial Fibrillation
For rapid AF during or after surgery, evaluate and treat contributing triggers such as pain, anemia and sepsis (Class 2a, C-LD). If rapid AF causes hemodynamic instability with hypotension, perform synchronized direct-current cardioversion.[1] Postoperative anticoagulation can benefit selected patients with new-onset AF after weighing thromboembolism against surgical bleeding (Class 2a, C-LD). Arrange outpatient thromboembolic-risk assessment and AF surveillance because recurrence is common (Class 1, C-LD).[1]
Other Guideline Frameworks
| Guideline | Distinguishing features |
|---|---|
| 2022 ESC | For known CVD, cardiovascular risk factors (including age ≥65), or suggestive symptoms with intermediate- or high-risk surgery, recommends high-sensitivity troponin before surgery and at 24 and 48 hours afterward (Class I, B), and considers preoperative BNP/NT-proBNP (Class IIa, B).[8] |
| 2017 CCS | For noncardiac surgery requiring an overnight stay, strongly recommends BNP/NT-proBNP measurement at age ≥65, age 45–64 with significant cardiovascular disease, or RCRI ≥1; to obtain daily troponin for 48–72 hours afterward in those with an elevated preoperative value (or, without a preoperative value, in the same age/RCRI groups); against routine preoperative echocardiography, stress testing or coronary CT; and to withhold ACE inhibitors/ARBs from 24 hours before surgery. Strongly recommends against initiating aspirin to prevent perioperative cardiac events, and against continuing aspirin for that purpose except after recent coronary stenting or for carotid endarterectomy[7] |
The AHA/ACC pathway is more permissive of selective stress testing and treats troponin surveillance as optional ("may be reasonable"). The CCS approach makes natriuretic-peptide-based stratification and postoperative troponin surveillance the default in older patients.
GU Reconstruction: Practical Points
- For cystectomy with diversion, major pelvic reconstruction and open nephrectomy, estimate combined patient-procedure cardiovascular risk before applying the biomarker and surveillance criteria above.[1]
- In older men and women having elective reconstruction (posterior urethroplasty, prosthesis or sling revision, AUS), a structured functional-capacity assessment is often the highest-yield single step.
- After pelvic cancer therapy, document cardiovascular symptoms, established disease and risk factors. In a retrospective cohort of older men treated for localized prostate cancer, radiotherapy and androgen deprivation were associated with more coronary events; apply the usual patient- and procedure-based criteria for ECG and biomarkers.[16][1]
- Robotic pelvic surgery adds steep Trendelenburg and pneumoperitoneum. Patients with severe aortic stenosis or ventricular dysfunction need echocardiography-informed hemodynamic planning.
- Chronic kidney disease is frequent and affects both risk (RCRI creatinine criterion) and medication choices.
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
7. 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(1):17–32. doi:10.1016/j.cjca.2016.09.008
8. Halvorsen S, Mehilli J, Cassese S, et al. 2022 ESC Guidelines on cardiovascular assessment and management of patients undergoing non-cardiac surgery. Eur Heart J. 2022;43(39):3826–3924. doi:10.1093/eurheartj/ehac270
9. 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(10):1043–1049. doi:10.1161/01.cir.100.10.1043
10. 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(9):855–863. doi:10.1007/s12630-013-9988-5
11. Ford MK, Beattie WS, Wijeysundera DN. Systematic review: prediction of perioperative cardiac complications and mortality by the revised cardiac risk index. Ann Intern Med. 2010;152(1):26–35. doi:10.7326/0003-4819-152-1-201001050-00007
12. Devereaux PJ, Yang H, Yusuf S, et al. Effects of extended-release metoprolol succinate in patients undergoing non-cardiac surgery (POISE trial): a randomised controlled trial. Lancet. 2008;371(9627):1839–1847. doi:10.1016/S0140-6736(08)60601-7
13. Devereaux PJ, Mrkobrada M, Sessler DI, et al. Aspirin in patients undergoing noncardiac surgery. N Engl J Med. 2014;370(16):1494–1503. doi:10.1056/NEJMoa1401105
14. Botto F, Alonso-Coello P, Chan MT, et al. Myocardial injury after noncardiac surgery: a large, international, prospective cohort study establishing diagnostic criteria, characteristics, predictors, and 30-day outcomes. Anesthesiology. 2014;120(3):564–578. doi:10.1097/ALN.0000000000000113
15. Thompson A, Fleischmann KE, Smilowitz NR, et al. "2026 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM Guideline for Perioperative Cardiovascular Management for Noncardiac Surgery: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines." J Am Coll Cardiol. 2026;88(13):1543–1643. doi:10.1016/j.jacc.2026.06.017
16. Wallis CJD, Mahar AL, Satkunasivam R, et al. "Cardiovascular and Skeletal-related Events Following Localized Prostate Cancer Treatment: Role of Surgery, Radiotherapy, and Androgen Deprivation." Urology. 2016;97:145–152. doi:10.1016/j.urology.2016.08.002