MedCalc: Perioperative Cardiac Evaluation
Guidelines for Perioperative Cardiovascular Evaluation for Noncardiac Surgery
American College of Cardiology / American Heart Association
JACC 1996; 27:910-948; and Circulation 1996; 93:1278-1317.
Pocket Guideline: requires Adobe Acrobat Reader
Need for cardiac surgery?

Emergency surgery
Urgent or elective surgery

Proceed to the Operating Room.

Postoperative risk stratification and risk factor management.

Coronary revascularization within 5 years?

Yes
No

Recurrent symptoms or signs?

Yes
No

Recent coronary evaluation?

Yes
No

Recent coronary angiogram or stress test?

Favorable result and no change in symptoms
Unfavorable result or change in symptoms

Proceed to Operating Room
Clinical Predictors:

Major Clinical Predictors:
Unstable coronary symptoms

l Recent MI (< 1 month ago) with evidence of important ischemic risk by clinical symptoms or noninvasive study
l Unstable or severe angina (Canadian Cardiovascular Society Class III or IV)
Decompensated CHF
Significant arrhythmias
l High-grade atrioventricular block
l Symptomatic ventricular arrhythmias in the presence of underlying heart disease
l Supraventricular arrhythmias with uncontrolled ventricular rate
Severe valvular disease

Intermediate Clinical Predictors:
Mild angina pectoris (Canadian Cardiovascular Society Class I or II)
Prior MI (by history or pathological waves)
Compensated or prior CHF
Diabetes mellitus

Minor Clinical Predictors:
Advanced age
Abnormal EKG (LV hypertrophy, LBBB, ST-T abnormalities)
Rhythm other than sinus (eg. atrial fibrillation)
Low functional capacity (eg. unable to climb one flight of stairs with a bag of groceries)
History of stroke
Uncontrolled systemic hypertension

  • Consider delay or cancel noncardiac surgery
  • Medical management and risk factor modification
  • Consider coronary angiography
  • Subsequent care dictated by findings and treatment results
    Subsequent care may include cancellation or delay of surgery, coronary revascularization followed by noncardiac surgery, or intensified care.
    Intermediate Clinical Predictors

    Functional Capacity:
    Poor (< 4 METs) (what's this?)
    Moderate or excellent (> 4 METs) (what's this?)

    Surgical Risk:
    High risk surgical procedure (what's this?)
    Intermediate surgical risk procedure (what's this?)
    Low surgical risk procedure (what's this?)

    Results of Non-Invasive Testing:
    Myocardial perfusion imaging or stress echocardiography

    Low risk
    High risk

  • Consider coronary angiography.
  • Subsequent care dictated by findings and treatment results
    Subsequent care may include cancellation or delay of surgery, coronary revascularization followed by noncardiac surgery, or intensified care.
  • Minor Clinical Predictors

    Functional Capacity:
    Poor (< 4 METs) (what's this?)
    Moderate or excellent (> 4 METs) (what's this?)

    Minor Clinical Predictors

    Surgical Risk:
    Intermediate surgical risk procedure (what's this?)
    High risk surgical procedure (what's this?)


    Created: Saturday, July 14, 2001
    Last Modified: