Clinical Quick Reference — Non-Cardiac Surgery Management
Breast, dental, endocrine, eye, gynecological minor, orthopedic minor, superficial surgery
Carotid surgery, endovascular aortic aneurysm repair, head/neck surgery, major intraperitoneal/intrapelvic surgery, peripheral artery angioplasty, renal transplant, urological major surgery
Adrenal resection, aortic and major vascular surgery, duodenopancreatectomy, esophagectomy, major vascular reconstruction for ischemia, pneumonectomy/lobectomy, repair of perforated bowel, total cystectomy
| Assessment Method | Definition | Clinical Use |
|---|---|---|
| METs (Metabolic Equivalents) | ≥4 METs: climb 2 flights of stairs, walk up hill | Good functional capacity, lower risk |
| DASI (Duke Activity Status Index) | Questionnaire-based; 0-58.2 score | Estimate METs; validate functional capacity |
| Frailty Assessment | Grip strength, gait speed, physical activity | Essential in patients ≥70 years |
BNP/NT-proBNP: Elevated levels independently predict perioperative complications in high-risk patients
High-sensitivity cardiac troponin: Baseline measurement helpful; serial measurement post-op critical for detecting MINS
Recommendation: Measure in intermediate-to-high-risk patients; use for risk stratification and perioperative surveillance
Baseline hs-cTn: Measure in intermediate-to-high-risk patients
Serial measurement: Day 1 and day 2 post-operatively
Perioperative MI (MINS): Defined as elevated troponin ≥99th percentile on post-operative day 1-2
Consider measuring: High-risk patients with CVD, HF, or risk factors
Prognostic value: Elevated levels independently predict perioperative complications
Indicated: Poor functional capacity, suspected HF, elevated BNP/NT-proBNP, or signs/symptoms of new/worsening cardiac disease
Assessment: LV systolic function, diastolic dysfunction, RV function, valvular disease, pericardial effusion
NOT recommended: Routine pre-operative evaluation of LV function in asymptomatic patients
Consider: High-risk elective NCS with poor functional capacity and high likelihood of CAD/symptoms
Modalities: Exercise stress test, dobutamine stress echocardiography (DSE), myocardial perfusion imaging (MPI)
NOT routinely recommended: Before low- or intermediate-risk NCS in asymptomatic patients
Consider: Unstable CAD, recent ACS, STEMI/NSTEMI — use same indications as non-surgical setting
CCTA: Alternative to rule out CAD in selected stable patients with abnormal stress test
NOT recommended: Routine pre-operative ICA in stable CCS patients undergoing low-/intermediate-risk NCS
| Agent | Timing After Recent PCI | Pre-operative Timing |
|---|---|---|
| Aspirin (low-dose) | Already on therapy | Continue perioperatively for secondary prevention |
| Clopidogrel | ≥5 days after PCI | Withhold 5 days pre-op if bleeding risk acceptable |
| Ticagrelor | 3-5 days (minimize duration) | Withhold 3-5 days pre-op |
| Prasugrel | 7 days | Withhold 7 days pre-op |
Normal renal function (CrCl >30): Stop 24 hours before elective NCS
Reduced renal function (CrCl 15-30): Stop 48 hours before NCS
Post-operative restart: Resume as soon as hemostasis achieved (typically 12-24 hours post-op)
High bleeding risk: Consider temporary bridging with UFH or prophylactic anticoagulation
Risk: Severe AS (AVA <1 cm² or peak gradient >4 m/s) is high-risk for NCS
Management: Consider valve intervention (SAVR, TAVI, balloon aortic valvuloplasty) before elective NCS if feasible
Intra-operative: Avoid tachycardia and hypotension; maintain preload
Mitral stenosis: High perioperative risk; consider valve intervention or careful hemodynamic management with controlled fluid balance
Mitral/aortic regurgitation: Lower risk; individualize based on severity and LV function
Rate control: Target resting heart rate <110 bpm perioperatively
Anticoagulation: Continue if CHA₂DS₂-VASc ≥2; balance thromboembolism vs. bleeding risk
Medications: Beta-blockers or non-dihydropyridine CCBs for rate control
Recommendation: Consult ACHD specialist before intermediate- or high-risk elective NCS
Regional vs. General: Individualize based on surgery type, patient factors, and institutional expertise
Regional anesthesia: May reduce perioperative mortality vs. general anesthesia in some high-risk settings
General anesthesia: Acceptable with appropriate hemodynamic monitoring and management
Definition: Elevated troponin ≥99th percentile on day 1-2 post-op (with or without ischemic symptoms)
Differential diagnosis: Type 1 MI (ACS with plaque rupture), Type 2 MI (supply-demand mismatch), and missed type
Management: Identify underlying cause (ischemia, sepsis, anemia, hypoxia); treat accordingly with ICA if STEMI
Incidence: 2-30% after major surgery (higher in elderly, cardiac surgery)
Rate control: Beta-blockers, non-dihydropyridine CCBs, digoxin
Anticoagulation: Indicated if CHA₂DS₂-VASc ≥2 for stroke prevention
Prevention: Perioperative beta-blockers effective; consider amiodarone in highest-risk
Risk factors: Pre-existing HF, excessive fluid administration, arrhythmia, myocardial injury
Management: Diuretics, vasodilators, inotropes (dobutamine, milrinone) if needed; ICU monitoring
Pathophysiology: Hypoperfusion, contrast-induced, myoglobinuria, hemoglobinuria
Prevention: Maintain renal perfusion pressure, minimize contrast, careful fluid management
Incidence: 0.2-0.9% after major surgery
Risk factors: Advanced age, atherosclerosis, AF, hypercoagulability, cardiac disease, carotid disease
Prevention: Optimize perioperative BP control, continue anticoagulation when feasible, carotid imaging in high-risk
Prophylaxis strategy: Risk-based (low/intermediate/high bleeding risk + surgery type)
Mechanical: Early mobilization, compression stockings/devices
Pharmacologic: LMWH, fondaparinux, warfarin, apixaban (per guideline protocols)
Use these interactive tools to assess perioperative cardiovascular risk and guide clinical decisions:
Calculate glomerular filtration rate for medication dosing and contrast consideration
Estimate renal function for drug adjustment and DOAC management
Comprehensive cardiac risk assessment for major surgery
10-year atherosclerotic cardiovascular disease risk estimation
Acute coronary syndrome risk stratification
Stroke risk in atrial fibrillation for anticoagulation decisions
Major bleeding risk in anticoagulated patients
QTc correction for arrhythmia risk assessment
Pulmonary embolism pretest probability assessment
Acute coronary syndrome mortality prediction
10-year coronary heart disease risk prediction
Perioperative cardiovascular complications depend on BOTH patient-related risk AND surgery-related risk. Comprehensive preoperative assessment integrated with multidisciplinary team involvement and individualized perioperative management optimize outcomes and reduce mortality.
Functional capacity (ability to climb two flights of stairs or walk uphill) is a powerful predictor of perioperative cardiovascular complications. Frailty assessment is essential in older patients and guides risk stratification and management intensity.
Perioperative troponin elevation (MINS) is common after major surgery and associated with worse outcomes. Serial measurement (baseline, day 1, day 2 post-op) and systematic workup to identify underlying cause (ischemia vs. supply-demand mismatch) guide therapy.
Routine preoperative investigations (ECG, TTE, stress testing) in asymptomatic low-risk patients DO NOT improve outcomes. Over-investigation delays surgery, increases costs, and can lead to unnecessary cascading testing and interventions. Use clinical judgment and risk stratification.
Do NOT routinely initiate beta-blockers immediately before non-cardiac surgery for cardioprotection. Beta-blockers in non-beta-blocked patients may cause harm (hypotension, stroke). Perioperative β-blockade requires careful individualization and is NOT recommended as a blanket strategy.
Abrupt discontinuation of chronic beta-blocker therapy perioperatively increases CV complications. Always maintain beta-blockers in patients on chronic therapy unless specific contraindications; dose adjustments acceptable.