Appropriate Use Criteria for Multimodality Imaging in Cardiovascular Evaluation of Noncardiac Surgery
Metabolic Equivalent of Task (MET) — One MET = 3.5 mL O₂/kg/min at rest. Patient exercise tolerance:
| Functional Level | METs | Examples |
|---|---|---|
| Poor | <4 METs | Cannot climb stairs, limited self-care, dyspnea at rest or minimal exertion |
| Moderate | 4–10 METs | Can climb stairs, walk >2 blocks, light household work |
| Excellent | >10 METs | Strenuous sports, heavy labor, vigorous exercise |
| Category | Definition |
|---|---|
| No Known/Suspected HD | No prior cardiac events, no abnormal testing, no cardiac risk factors |
| Known/Suspected Ischemic HD | History of prior MI, abnormal stress test, prior CAD, ischemic ECG findings |
| Known/Suspected VHD/HF | Valve disease by echo, structural dysfunction, clinical HF signs, elevated BNP |
Appropriateness of preoperative imaging based on estimated risk of major adverse cardiovascular events (MACE) — MI or cardiovascular death within 30 days.
Endocrine, gynecologic, dental, ophthalmologic, dermatologic, minor orthopedic procedures
Carotid endarterectomy, head/neck surgery, intra-abdominal, orthopedic, urologic procedures
Vascular (aortic, major vascular), thoracic/abdominal aortic aneurysm, esophageal, liver transplant, major orthopedic
Predicts major cardiac complications (MI, pulmonary edema, VT, cardiac death) after noncardiac surgery.
6 Independent Predictors: (1) High-risk surgery, (2) Ischemic heart disease, (3) Congestive heart failure, (4) Cerebrovascular disease, (5) Diabetes on insulin, (6) Serum creatinine >2 mg/dL
Risk: 0 factors = 0.4% | 1 = 1% | 2 = 2.4% | ≥3 = 5.4%
More granular, procedure-specific risk calculator. Available at nsqip.facs.org/riskcalculator.
| Biomarker | Use |
|---|---|
| Troponin (cTn) | Baseline measurement stratifies risk; elevated preop = high-risk patient |
| BNP / NT-proBNP | Elevated levels correlate with increased perioperative cardiac risk and HF diagnosis |
Asymptomatic patients without known/suspected heart disease and no recent cardiac testing. Decision to test based on functional capacity and surgical risk.
| Clinical Scenario | TTEe | Stress Echo | MPI | CCTA | Cath |
|---|---|---|---|---|---|
| Asymp, ≥4 METs, Low-Risk Sx | 1 (R) | 1 (R) | 1 (R) | 1 (R) | 1 (R) |
| Asymp, ≥4 METs, Int-Risk Sx | 1 (R) | 1 (R) | 1 (R) | 1 (R) | 1 (R) |
| Asymp, ≥4 METs, High-Risk Sx | 4 (M) | 4 (M) | 4 (M) | 3 (R) | 1 (R) |
| Asymp, <4 METs, Low-Risk Sx | 3 (R) | 3 (R) | 2 (M) | 2 (M) | 1 (R) |
| Asymp, <4 METs, Int-Risk Sx | 4 (M) | 4 (M) | 4 (M) | 3 (R) | 1 (R) |
| Asymp, <4 METs, High-Risk Sx | 7 (A) | 4 (M) | 5 (M) | 5 (M) | 3 (R) |
Legend: 7–9 = Appropriate (A, green) | 4–6 = May Be Appropriate (M, yellow) | 1–3 = Rarely Appropriate (R, red)
Patients with recent cardiac testing (90–220 days) and known/suspected CAD, VHD, or HF. Prior results inform risk stratification; interval clinical change may warrant repeat imaging.
| Clinical Scenario | TTEe | Stress Echo | MPI | CCTA |
|---|---|---|---|---|
| Known CAD, No Sx, ≥4 METs | 1 (R) | 1 (R) | 1 (R) | 1 (R) |
| Known CAD, New Sx, <4 METs | 4 (M) | 7 (A) | 5 (M) | 6 (A) |
| Known HF, Stable, ≥4 METs | 1 (R) | 1 (R) | 1 (R) | 1 (R) |
| Known HF, Decompensated, <4 METs | 7 (A) | 3 (R) | 1 (R) | 1 (R) |
Most detailed section. Recent testing (≤90 days) provides excellent risk stratification. Repeat imaging typically needed only if new/worsening symptoms or marked functional decline since prior test.
In patients with recent (≤90 days) high-quality imaging and stable clinical presentation, repeat testing is rarely appropriate. Reserve repeat imaging for new symptoms, clinical deterioration, or high-risk surgery requiring updated risk assessment.
| Patient Presentation | TTEe | TEE | Stress Echo | Assessment |
|---|---|---|---|---|
| Known Severe CAD, Normal Stress, Asymp, ≥4 METs | 1 (R) | 1 (R) | 1 (R) | 1 (R) |
| Known VHD, No WMA, Asymp, ≥4 METs | 1 (R) | 1 (R) | 1 (R) | 1 (R) |
| Known Moderate VHD, New Dyspnea, <4 METs | 7 (A) | 4 (M) | 5 (M) | 6 (A) |
| Suspected Severe HF, Unknown EF, Dyspneic | 8 (A) | 3 (R) | 1 (R) | 1 (R) |
Reserved for high-risk patients with indications for revascularization prior to surgery or acute presentation with ACS-like symptoms. Rarely appropriate purely for perioperative risk stratification in stable patients.
Preoperative Management:
Often asymptomatic at rest; perioperative risk driven by diastolic dysfunction, elevated filling pressures, and fluid responsiveness. Echo assessment of diastolic parameters helpful for risk stratification.
| Valve Lesion | Preoperative Assessment | Perioperative Pearl |
|---|---|---|
| Aortic Stenosis (AS) | Severity by AVA, peak gradient. AVA <1 cm² = severe. | Severe AS with symptoms = very high perioperative risk; consider postponing elective surgery. |
| Aortic Regurgitation (AR) | EF, LV size, regurgitant volume. Acute AR = emergency. | Chronic severe AR tolerated if EF >40%; maintain afterload reduction. |
| Mitral Stenosis (MS) | MVA <1.5 cm² = severe; risk of atrial fibrillation and HF. | Very high perioperative risk; consider β-blocker optimization, anticoagulation if AF. |
| Mitral Regurgitation (MR) | Severity, EF, LV size. Secondary MR common in cardiomyopathy. | Acute severe MR = emergency. Chronic tolerated if EF >30%. |
Patients with both significant CAD and VHD face compounded perioperative risk. Preoperative imaging should clearly delineate severity of both lesions to guide surgical planning and perioperative management.
Baseline HF staging by HF cardiologist or transplant team essential. Perioperative blood pressure, anticoagulation, and device-specific management critical.
Use these calculators to quantify perioperative cardiac risk, assess functional capacity, and inform preoperative imaging decisions:
Pooled Cohort Equations for 10-year cardiovascular risk estimation in primary prevention.
European cardiac surgery mortality risk prediction. Useful for high-risk perioperative patients undergoing vascular surgery.
Acute coronary syndrome risk stratification. Guides admission and testing decisions in chest pain presentation.
Renal function estimation. Essential for contrast-based imaging decisions and medication dosing.
Grade severity by AVA and pressure gradient. Guides perioperative planning in patients with AS.