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surgery.preop-cardiac-evaluation.core.v1

Preoperative Cardiac Risk Evaluation (Noncardiac Surgery)

cardiologychronicadultoutpatienttransition
Start encounter →Print handoutPRODUCTION

Preoperative cardiac risk evaluation engine for noncardiac surgery — chronic / outpatient. 2024 AHA/ACC Perioperative (Thompson PMID 39316661) is current floor; supersedes 2014. RCRI (Lee 1999 PMID 10477528) is the core stratification tool; not yet registered as a calculator in clinical-tools-registry (embedded in workup.preop_cardiac and risk_stratification rationale). Key drug-management rules: CONTINUE chronic beta-blocker + statin; DO NOT initiate new beta-blocker just pre-op (POISE PMID 18479744); DO NOT initiate new aspirin (POISE-2 PMID 24679062); HOLD ACEi/ARB morning of surgery (Class IIb). Workup workup.preop_cardiac registered in clinical-tools-registry. All PMIDs + RxCUIs live-verified 2026-05-26.

Entry points (6)

  • problem_list
    Planned noncardiac surgery — preoperative clinic referral (2024 AHA/ACC Perioperative)
    planned_noncardiac_surgery
  • history
    History of ischemic heart disease / prior MI / PCI / CABG (RCRI element) (Lee 1999 PMID 10477528)
    ischemic_heart_disease
  • history
    History of CHF (RCRI element) (Lee 1999 PMID 10477528)
    heart_failure
  • history
    History of stroke / TIA (RCRI element) (Lee 1999 PMID 10477528)
    cerebrovascular_disease
  • history
    Insulin-treated diabetes mellitus (RCRI element) (Lee 1999 PMID 10477528)
    insulin_treated_diabetes
  • lab_abnormality
    Serum creatinine >2.0 mg/dL (RCRI element) (Lee 1999 PMID 10477528)
    cr_above_2

Required inputs (16)

  • agerequired
    demographic • used at CONTEXT
    Age >=65 favors GSCRI over RCRI for cardiac risk (Alrezk 2017 PMID 29146612)
  • sex
    demographic • used at CONTEXT
    Risk stratification differs; informs functional capacity benchmarks (2024 AHA/ACC Perioperative)
  • sbprequired
    vital • used at CONTEXT
    Baseline BP for perioperative hypotension threshold; chronic HTN management (2024 AHA/ACC Perioperative)
  • hrrequired
    vital • used at CONTEXT
    Baseline rhythm; AF detection alters anticoagulation bridging (2024 AHA/ACC Perioperative)
  • creatininerequired
    lab • used at INITIAL_WORKUP
    RCRI element (Cr >2 = 1 point); also informs contrast nephropathy + meds dosing (Lee 1999 PMID 10477528)
  • hemoglobinrequired
    lab • used at INITIAL_WORKUP
    Anemia raises perioperative MACE; correctable preoperatively (2024 AHA/ACC Perioperative)
  • bnp_or_nt_probnp
    lab • used at INITIAL_WORKUP
    2024 guideline Class IIa — elevated BNP/NT-proBNP risk-stratifies (>=300 NT-proBNP / >=92 BNP) (2024 AHA/ACC Perioperative)
  • troponin
    lab • used at INITIAL_WORKUP
    Preoperative troponin for surveillance baseline in high-risk patients (2024 AHA/ACC Perioperative)
  • a1c
    lab • used at INITIAL_WORKUP
    Glycemic control optimization pre-op; A1c >8 is preventable risk factor (2024 AHA/ACC Perioperative)
  • ecg_baseline
    imaging • used at INITIAL_WORKUP
    Baseline ECG for high-risk patients or known cardiac disease (2024 AHA/ACC Perioperative)
  • echo_lvef
    imaging • used at BRANCHING_WORKUP
    Echo if dyspnea/HF symptoms or murmur — LVEF guides risk + management (2024 AHA/ACC Perioperative)
  • functional_capacity_metsrequired
    history • used at CONTEXT
    DASI / METs (<4 = poor functional capacity, increases risk) (2024 AHA/ACC Perioperative)
  • recent_mi_or_stent
    history • used at CONTEXT
    MI <60d / DES <6-12 mo postpone elective surgery; alters DAPT plan (2024 AHA/ACC Perioperative)
  • active_cardiac_conditionsrequired
    history • used at RED_FLAGS
    Unstable angina / decompensated HF / severe AS / arrhythmia -> POSTPONE elective surgery (2024 AHA/ACC Perioperative)
  • planned_surgery_typerequired
    history • used at CONTEXT
    Surgery risk category (low <1% / intermediate / high >5%) drives RCRI weighting (2024 AHA/ACC Perioperative)
  • current_medsrequired
    medication • used at CONTEXT
    Beta-blocker / statin / DAPT / anticoagulant management plan (2024 AHA/ACC Perioperative)

12-phase flow (10)

  1. 1FRAME
    Confirm patient is non-emergent, undergoing noncardiac surgery, needs cardiac risk stratification; active cardiac conditions -> POSTPONE pathway (2024 AHA/ACC Perioperative)
    inputs: planned_surgery_type, active_cardiac_conditions
    advance: elective / non-emergent surgery confirmed
  2. 2ENTRY
    Preoperative clinic referral; chronic CV history / problem list (2024 AHA/ACC Perioperative)
    inputs: age
    advance: entry trigger captured
  3. 3CONTEXT
    Comorbidities (DM/CKD/HTN/HF/CAD/AF/PAD), functional capacity METs, current meds, prior MI / PCI / CABG / stroke, surgery type / risk class (2024 AHA/ACC Perioperative)
    inputs: sbp, hr, functional_capacity_mets, recent_mi_or_stent, planned_surgery_type, current_meds
    advance: context complete
  4. 4INITIAL_WORKUP
    Baseline ECG (high-risk pts), CBC, BMP, A1c if DM, BNP/NT-proBNP if Class IIa indication; echo only if dyspnea / new murmur / known HF (2024 AHA/ACC Perioperative)
    inputs: creatinine, hemoglobin, bnp_or_nt_probnp, ecg_baseline
    actions: panel.cbc, panel.renal, panel.cardiac
    advance: baseline studies obtained
  5. 5BRANCHING_WORKUP
    Stress test / echo only if it WILL change management AND functional capacity <4 METs AND high-risk surgery (2024 AHA/ACC Perioperative Class IIa); CT angio rarely indicated pre-op (Class III)
    inputs: echo_lvef
    advance: further testing pursued or excluded based on guideline algorithm
  6. 6RISK_STRATIFICATION
    RCRI (Lee 1999) for adults; GSCRI for >=65 (Alrezk 2017); Gupta MICA for surgery-specific calibration. Map RCRI score to MACE risk class: 0=0.5%, 1=1.3%, 2=4%, >=3=9% (Lee 1999 PMID 10477528)
    inputs: age, creatinine, functional_capacity_mets, planned_surgery_type
    actions: workup.preop_cardiac
    advance: risk class assigned
  7. 7TREATMENT
    Optimize chronic disease (BP / lipid / glycemia / HF / arrhythmia); medication management plan: CONTINUE beta-blocker / statin / ACEi (cautious); HOLD ACEi/ARB morning of surgery (Class IIb); MANAGE antithrombotics by surgical bleeding risk + indication; rarely add or initiate new meds pre-op (2024 AHA/ACC Perioperative)
    inputs: current_meds, sbp, hr, a1c
    advance: med plan documented + handoff to surgical team
  8. 8DISPOSITION
    Clear for surgery (low risk) / Conditional clearance with monitoring (intermediate) / Postpone for optimization (active cardiac condition / severe AS / unstable arrhythmia) (2024 AHA/ACC Perioperative)
    advance: disposition decision documented for surgical team
  9. 9MONITORING
    Postoperative troponin x 24-48h in high-risk patients (Class IIa); BP / HR / rhythm; signs of MINS (myocardial injury after noncardiac surgery) (2024 AHA/ACC Perioperative)
    inputs: troponin
    actions: panel.cardiac
    advance: postoperative monitoring plan in place
  10. 10FOLLOWUP
    Post-discharge cardiology follow-up if MINS / new MI / new arrhythmia; resume held meds (ACEi/ARB / antithrombotics) per surgical bleeding clearance; vaccination, lifestyle counseling (2024 AHA/ACC Perioperative)
    advance: follow-up + medication resumption plan in place