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surgery.preop-cardiac-evaluation.core.v1PRODUCTION
surgery.preop-cardiac-evaluation.core.v1

Preoperative Cardiac Risk Evaluation (Noncardiac Surgery)

cardiologychronicadult
Hard-required inputs
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Care setting:

Encounter flow

10/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

Confirm patient is non-emergent, undergoing noncardiac surgery, needs cardiac risk stratification; active cardiac conditions -> POSTPONE pathway (2024 AHA/ACC Perioperative)

Inputs
2
Actions
0
Advance rule
Set
Advance when

elective / non-emergent surgery confirmed

Patient inputs (16)

Age >=65 favors GSCRI over RCRI for cardiac risk (Alrezk 2017 PMID 29146612)

Baseline BP for perioperative hypotension threshold; chronic HTN management (2024 AHA/ACC Perioperative)

Baseline rhythm; AF detection alters anticoagulation bridging (2024 AHA/ACC Perioperative)

DASI / METs (<4 = poor functional capacity, increases risk) (2024 AHA/ACC Perioperative)

Surgery risk category (low <1% / intermediate / high >5%) drives RCRI weighting (2024 AHA/ACC Perioperative)

Beta-blocker / statin / DAPT / anticoagulant management plan (2024 AHA/ACC Perioperative)

RCRI element (Cr >2 = 1 point); also informs contrast nephropathy + meds dosing (Lee 1999 PMID 10477528)

Anemia raises perioperative MACE; correctable preoperatively (2024 AHA/ACC Perioperative)

Unstable angina / decompensated HF / severe AS / arrhythmia -> POSTPONE elective surgery (2024 AHA/ACC Perioperative)

Echo if dyspnea/HF symptoms or murmur — LVEF guides risk + management (2024 AHA/ACC Perioperative)

Risk stratification differs; informs functional capacity benchmarks (2024 AHA/ACC Perioperative)

MI <60d / DES <6-12 mo postpone elective surgery; alters DAPT plan (2024 AHA/ACC Perioperative)

2024 guideline Class IIa — elevated BNP/NT-proBNP risk-stratifies (>=300 NT-proBNP / >=92 BNP) (2024 AHA/ACC Perioperative)

Preoperative troponin for surveillance baseline in high-risk patients (2024 AHA/ACC Perioperative)

Glycemic control optimization pre-op; A1c >8 is preventable risk factor (2024 AHA/ACC Perioperative)

Baseline ECG for high-risk patients or known cardiac disease (2024 AHA/ACC Perioperative)

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (5)

5 need judgement
  • informationalsevereactive_cardiac_condition_postpone
    Unstable angina / decompensated HF / severe AS / uncontrolled arrhythmia — POSTPONE elective noncardiac surgery (2024 AHA/ACC Perioperative)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevererecent_mi_within_60_days
    MI within 60 days — postpone elective surgery; balance with surgical urgency (2024 AHA/ACC Perioperative)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevererecent_des_within_6_months
    DES placed within 6 months / BMS within 30 days — postpone elective surgery; continue DAPT if must proceed urgently (2024 AHA/ACC Perioperative)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveresevere_aortic_stenosis_preop
    Severe AS (AVA <1.0, mean gradient >40, peak velocity >4) — postpone or transcatheter valve before surgery (2024 AHA/ACC Perioperative)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatercri_above_3_high_mace
    RCRI >=3 + poor functional capacity (<4 METs) + high-risk surgery (>5% MACE) — consider further testing if it changes management (Lee 1999 PMID 10477528; 2024 AHA/ACC Perioperative)
    Trigger could not be auto-evaluated — needs clinician judgement.

Workflow calculators

Run this disease's risk and dosing calculators inline.

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Recommended regimen

Perioperative cardiac medication management — by class + indication (2024 AHA/ACC Perioperative)
axis: preop_cardiac_med_managementstep 1 - Step 1 — Beta-blocker management (CONTINUE chronic, DO NOT initiate within 1 day of surgery)
Selected step "Step 1 — Beta-blocker management (CONTINUE chronic, DO NOT initiate within 1 day of surgery)" — Patient on chronic beta-blocker OR considering initiation
  • metoprolol succinate
    first line
    beta1_blocker_extended_release
    25-200 mg PO daily (continue chronic dose; do not initiate within 1 day pre-op) • PO • once daily
    triggers: chronic_beta_blocker_user, CAD_or_HF_indication
    CONTINUE chronic beta-blocker — Class I 2024 AHA/ACC Perioperative (PMID 39316661). POISE 2008 (PMID 18479744): INITIATING metoprolol succinate within 1 day of surgery -> reduced MI (HR 0.73) but INCREASED total death (HR 1.33) and stroke (HR 2.17). Class III for new initiation just before surgery.
    rxcui 221124
  • metoprolol
    add on
    beta1_blocker
    Per chronic regimen (do not initiate just pre-op) • PO • BID
    triggers: chronic_tartrate_use, thyrotoxic_atrial_fibrillation
    Continue chronic metoprolol tartrate; alternative when extended-release unavailable (2024 AHA/ACC Perioperative)
    rxcui 6918

outpatient playbook — drug actions (6)

  1. 1. continue chronic beta-blocker (do not initiate new just pre-op)
    Per chronic regimen • PO • usual
    trigger: Chronic user (POISE 2008 — initiating just pre-op increases stroke/death; PMID 18479744)
    Class I continuation; Class III initiation (2024 AHA/ACC Perioperative)
  2. 2. continue chronic statin (initiate >=30 days pre-op if vascular surgery)
    High-intensity (atorvastatin 40-80 or rosuvastatin 20-40) • PO • once daily
    trigger: ASCVD or vascular surgery (2024 AHA/ACC Perioperative)
    Class I continuation; DECREASE-3 / LOAD
  3. 3. aspirin management per stent + bleed risk
    81 mg PO daily • PO • daily
    trigger: Established CAD/stent + acceptable bleed risk (POISE-2 PMID 24679062 — do not start new ASA)
    Continue chronic; do not initiate new perioperatively
  4. 4. P2Y12 management by stent timing
    Clopidogrel 75 mg / ticagrelor 90 BID / prasugrel 10 mg • PO • daily
    trigger: DES <6 mo / BMS <30d -> postpone elective; outside window -> hold 5-7d pre-op (2024 AHA/ACC Perioperative)
    Class I postpone within stent window
  5. 5. hold ACEi/ARB morning of surgery
    Per chronic • PO • morning hold
    trigger: Surgery day (Class IIb 2024 AHA/ACC Perioperative)
    Reduces intraop hypotension
  6. 6. anticoagulant bridging only for truly high TE risk
    Enoxaparin 1 mg/kg SC q12h bridge • SC • q12h
    trigger: Mechanical mitral / recent VTE / CHA2DS2-VASc >=7 (BRIDGE trial 2024 AHA/ACC Perioperative)
    Most AF does NOT need bridging

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Planned noncardiac surgery — preoperative clinic referral (2024 AHA/ACC Perioperative); History of ischemic heart disease / prior MI / PCI / CABG (RCRI element) (Lee 1999 PMID 10477528); History of CHF (RCRI element) (Lee 1999 PMID 10477528).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Preoperative Cardiac Risk Evaluation (Noncardiac Surgery)** (surgery.preop-cardiac-evaluation.core.v1).
Scope: Confirm patient is non-emergent, undergoing noncardiac surgery, needs cardiac risk stratification; active cardiac conditions -> POSTPONE pathway (2024 AHA/ACC Perioperative)

No severity triggers fired against current inputs.

Plan

Regimen axis: **Perioperative cardiac medication management — by class + indication (2024 AHA/ACC Perioperative)** — step "Step 1 — Beta-blocker management (CONTINUE chronic, DO NOT initiate within 1 day of surgery)".
1. metoprolol succinate 25-200 mg PO daily (continue chronic dose; do not initiate within 1 day pre-op) PO once daily (beta1_blocker_extended_release, first line) — CONTINUE chronic beta-blocker — Class I 2024 AHA/ACC Perioperative (PMID 39316661). POISE 2008 (PMID 18479744): INITIATING metoprolol succinate within 1 day of surgery -> reduced MI (HR 0.73) but INCREASED total death (HR 1.33) and stroke (HR 2.17). Class III for new initiation just before surgery.
2. metoprolol Per chronic regimen (do not initiate just pre-op) PO BID (beta1_blocker, add on) — Continue chronic metoprolol tartrate; alternative when extended-release unavailable (2024 AHA/ACC Perioperative)

Setting playbook (outpatient) — Stratify perioperative cardiac risk (RCRI + functional capacity + surgery risk), identify active conditions warranting postponement, optimize chronic disease, generate medication management plan, communicate to surgical/anesthesia team (2024 AHA/ACC Perioperative)
3. continue chronic beta-blocker (do not initiate new just pre-op) Per chronic regimen PO usual — Chronic user (POISE 2008 — initiating just pre-op increases stroke/death; PMID 18479744) (Class I continuation; Class III initiation (2024 AHA/ACC Perioperative))
4. continue chronic statin (initiate >=30 days pre-op if vascular surgery) High-intensity (atorvastatin 40-80 or rosuvastatin 20-40) PO once daily — ASCVD or vascular surgery (2024 AHA/ACC Perioperative) (Class I continuation; DECREASE-3 / LOAD)
5. aspirin management per stent + bleed risk 81 mg PO daily PO daily — Established CAD/stent + acceptable bleed risk (POISE-2 PMID 24679062 — do not start new ASA) (Continue chronic; do not initiate new perioperatively)
6. P2Y12 management by stent timing Clopidogrel 75 mg / ticagrelor 90 BID / prasugrel 10 mg PO daily — DES <6 mo / BMS <30d -> postpone elective; outside window -> hold 5-7d pre-op (2024 AHA/ACC Perioperative) (Class I postpone within stent window)
7. hold ACEi/ARB morning of surgery Per chronic PO morning hold — Surgery day (Class IIb 2024 AHA/ACC Perioperative) (Reduces intraop hypotension)
8. anticoagulant bridging only for truly high TE risk Enoxaparin 1 mg/kg SC q12h bridge SC q12h — Mechanical mitral / recent VTE / CHA2DS2-VASc >=7 (BRIDGE trial 2024 AHA/ACC Perioperative) (Most AF does NOT need bridging)

Non-pharmacologic actions:
- DASI questionnaire / 6-min walk for functional capacity (2024 AHA/ACC Perioperative)
- Smoking cessation counseling (delay 4-8 weeks if possible) (2024 AHA/ACC Perioperative)
- Optimize HTN to <140/90 (or <130/80 if CV disease) (2024 AHA/ACC Perioperative)
- Optimize A1c <8 ideally; severe hyperglycemia (>200) optimize first (2024 AHA/ACC Perioperative)
- Treat anemia (oral / IV iron) if elective and time allows (2024 AHA/ACC Perioperative)
- Vaccinate (flu / COVID / pneumococcal) per usual schedule (2024 AHA/ACC Perioperative)
- Generate written medication management plan for anesthesia / surgical team (2024 AHA/ACC Perioperative)

AVOID / contraindication checks:
- Do_NOT_initiate_beta_blocker_within_1_day_of_surgery_POISE (Devereaux 2008 PMID 18479744)
- Do_NOT_start_new_aspirin_for_perioperative_prevention_POISE_2 (Devereaux 2014 PMID 24679062)
- Postpone_elective_surgery_within_6_months_of_DES_or_30_days_of_BMS (2024 AHA/ACC Perioperative)
- Hold_ACEi_ARB_morning_of_surgery_Class_IIb (2024 AHA/ACC Perioperative)
- Continue_chronic_statin_perioperatively (2024 AHA/ACC Perioperative)
- Bridge_only_truly_high_thromboembolic_risk_BRIDGE_trial (2024 AHA/ACC Perioperative)

Monitoring

Regimen monitoring:
- perioperative BP within 20 percent of baseline (2024 AHA/ACC Perioperative)
- troponin q6 to 12h x 48h in high risk post op (2024 AHA/ACC Perioperative)
- ECG post op high risk or symptomatic (2024 AHA/ACC Perioperative)
- BMP post op for K Cr volume (2024 AHA/ACC Perioperative)
- resume chronic meds within 24 to 48h if stable (2024 AHA/ACC Perioperative)

Setting (outpatient) monitoring:
- Reassess at hospital admission day for any changes (2024 AHA/ACC Perioperative)
- Confirm chronic meds taken / held per plan on day of surgery (2024 AHA/ACC Perioperative)

Follow-up plan: 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)
- Close-out criterion: follow-up + medication resumption plan in place

Monitoring phase: 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)

Disposition

Current setting: outpatient — Stratify perioperative cardiac risk (RCRI + functional capacity + surgery risk), identify active conditions warranting postponement, optimize chronic disease, generate medication management plan, communicate to surgical/anesthesia team (2024 AHA/ACC Perioperative)

Disposition criteria:
- Cleared for surgery (low risk, optimized) (2024 AHA/ACC Perioperative)
- Conditional clearance — proceed with telemetry / continuous BP monitoring + post-op troponin x 48h (2024 AHA/ACC Perioperative)
- Postponed — active condition needs optimization first (2024 AHA/ACC Perioperative)

Escalation triggers (move to higher acuity):
- Active cardiac condition (unstable angina, decompensated HF, severe AS, uncontrolled arrhythmia) -> POSTPONE + cardiology consult (2024 AHA/ACC Perioperative)
- Recent MI <60d -> postpone elective surgery (2024 AHA/ACC Perioperative)
- Recent DES <6mo / BMS <30d -> postpone elective (2024 AHA/ACC Perioperative)
- New murmur on exam -> echo before surgery (2024 AHA/ACC Perioperative)
- RCRI >=3 + functional capacity <4 METs + high-risk surgery -> stress test consideration if will change management (2024 AHA/ACC Perioperative)

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [SEVERE] Unstable angina / decompensated HF / severe AS / uncontrolled arrhythmia — POSTPONE elective noncardiac surgery (2024 AHA/ACC Perioperative)
- [SEVERE] MI within 60 days — postpone elective surgery; balance with surgical urgency (2024 AHA/ACC Perioperative)
- [SEVERE] DES placed within 6 months / BMS within 30 days — postpone elective surgery; continue DAPT if must proceed urgently (2024 AHA/ACC Perioperative)

Citations

- 2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM Guideline for Perioperative Cardiovascular Management for Noncardiac Surgery (Thompson 2024) — supersedes 2014 ACC/AHA [PMID:39316661](https://pubmed.ncbi.nlm.nih.gov/39316661/)
- Cited evidence (PMID 39320289) [PMID:39320289](https://pubmed.ncbi.nlm.nih.gov/39320289/)
- Cited evidence (PMID 10477528) [PMID:10477528](https://pubmed.ncbi.nlm.nih.gov/10477528/)
- Cited evidence (PMID 29146612) [PMID:29146612](https://pubmed.ncbi.nlm.nih.gov/29146612/)
- Cited evidence (PMID 18479744) [PMID:18479744](https://pubmed.ncbi.nlm.nih.gov/18479744/)

Last reconciled with current guidelines: 2026-05-26.
References
  • 2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM Guideline for Perioperative Cardiovascular Management for Noncardiac Surgery (Thompson 2024) — supersedes 2014 ACC/AHA — PMID:39316661
  • Cited evidence (PMID 39320289) — PMID:39320289
  • Cited evidence (PMID 10477528) — PMID:10477528
  • Cited evidence (PMID 29146612) — PMID:29146612
  • Cited evidence (PMID 18479744) — PMID:18479744