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Cardiac risk assessment before non-cardiac surgery
Cardiac risk at surgery is set by three things — the type of operation, the patient's condition and functional capacity — and most stable patients go to surgery without further tests; what is unstable is fixed first.
Why it matters in the exam
The exam presents a patient with heart disease before surgery and asks whether to postpone, whether to do a stress test or coronary angiography, and what to do with the drugs: aspirin, clopidogrel after a stent, beta-blockers and statins. It also asks how long to wait after a stent before elective surgery, when the RCRI is high, and what to do with an implanted pacemaker or defibrillator when diathermy is used.
Good functional capacity — climbing two flights of stairs without stopping (about 4 METs) — predicts low risk, and usually no further cardiac tests are needed. The RCRI includes six factors: high-risk surgery, coronary disease, heart failure, cerebrovascular disease, diabetes treated with insulin and creatinine above 2 mg/dL. The 2022 ESC guideline recommends measuring troponin before intermediate- or high-risk surgery and at 24 and 48 hours after it in patients at risk, to detect myocardial injury that is usually painless.
Key points
- Risk = operation + patient + functional capacity.
- Unstable cardiac condition → postpone and treat.
- 4 METs or more → proceed without cardiac tests.
- After elective PCI — 6 months to elective surgery; after ACS — 12 months.
- Continue beta-blocker and statin; do not start a beta-blocker on the day of surgery.
Summary table
| Issue | Rule | Exam point |
|---|---|---|
| Surgical risk | Low below 1% (eye, breast, dental); intermediate 1%–5% (abdominal, major orthopaedic); high above 5% (aortic, major vascular, oesophageal, pancreatic) | Aortic and major vascular surgery carry the highest risk |
| Functional capacity | 4 METs or more (two flights) — proceed to surgery | Stress imaging only if capacity is poor and the surgery is high-risk |
| After a stent | Elective surgery — at least 6 months after elective PCI and 12 months after ACS | Time-sensitive surgery — at least 1 month (3 months after ACS) |
| Drugs | Continue beta-blocker, statin and usually aspirin; stop ticagrelor 3–5 days, clopidogrel 5 days, prasugrel 7 days | Do not start a high-dose beta-blocker on the day of surgery |
| Pacemaker / ICD | ICD — suspend shock therapies with diathermy above the umbilicus; magnet on a pacemaker — fixed-rate pacing | A magnet on an ICD stops shocks and does not change pacing |
Free exam questions
בן 65 , המעומד לניתוח right hemicolectomy , בשל סרטן, סובל מסכרת (מטופל מאינסולין), ברקע אירוע לבבי לפני 7 חודשים. בצינטור לבבי שהיה אז, הוכנסו DES . מאז הוא מקבל Plavix ו - aspirin. ה- creatinine שלו 2.5mg/dl . המטופל מסוגל לעלות שתי קומות במדרגות, ללא כאבים בחזה וללא קוצר נשימה. אין לו סימנים או סימ פטומים של אי- ספיקת לב, ולא היה לו אירוע מוחי בעבר מה ה ה מלצה לגבי מדללי דם לקראת הניתוח במטופל המתואר?למעלה (the question as examined, in Hebrew)
- א. להמשיך aspirin , אך להפסיק Plavix
- ב. להמשיך plavix ו aspirin
- ג. להפסיק aspirin , ולהמשיך plavix
- ד. לדחות את הניתוח עד ש י עבר ו שנתיים מאז האירוע לבבי כדי לאפשר הפסקת מדללי דם
למי מהמטופלים הבאים יש אינדיקצי ה להשתלת ICD ( Implantable Cardiac Defibrillators ) ? (the question as examined, in Hebrew)
- א. מטופל עם יה סטוריה של Paroxysmal Atrial Fibrillation
- ב. מטופל עם Ejection Fraction מתחת ל 40%
- ג. מטופל( לאחר ניתוח מעקפים CABG )
- ד. מטופל לאחר אירוע לבבי לאחרונה( Recent MI )
In the full version for subscribers
- A simple algorithm
- Memory aid
- Exam traps
- 5 review cards
- Enough for IMLE
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Sources
- ESC Guidelines on cardiovascular assessment and management of patients undergoing non-cardiac surgery, 2022 — Risk assessment, coronary disease, antithrombotic management
- 2024 AHA/ACC Guideline for Perioperative Cardiovascular Management for Noncardiac Surgery, 2024 — Stepwise approach
- Miller's Anesthesia, 9th edition (2020) — Preoperative Evaluation: Cardiovascular Disease
Sources are given for further reading; the text is written afresh and not copied from them.
Reviewed by the Examqo AI Professor · 2026-11-02. The text may contain errors; when in doubt, check the source.