Anesthesiology APPLIED Exam › Cardiovascular and cardiac anesthesia

Preoperative cardiac evaluation for non-cardiac surgery

Cardiovascular and cardiac anesthesia·~5 min read· Physician-reviewed✓ Sourced · 2

Stem

A 70-year-old man, 90 kg, is scheduled for elective total hip arthroplasty. He had a myocardial infarction six years ago, treated medically, and has insulin-treated type 2 diabetes and well-controlled hypertension; creatinine is 1.4 mg/dL. He takes metoprolol, atorvastatin, lisinopril and insulin. Despite his hip, he climbs two flights of stairs to his bedroom daily without chest pain or breathlessness. His ECG shows old inferior Q waves.

Question

What further cardiac evaluation does he need before surgery?

Ideal answer

HeadlineNo further testing. Elective surgery, no active cardiac condition, and his two RCRI factors are answered by four or more METs, so I proceed.

Urgency, then active conditions, then combined risk. Elective, and no acute coronary syndrome, decompensated heart failure, significant arrhythmia or severe valvular disease, any of which I would treat first.
A validated tool, RCRI or NSQIP: below 1% risk of a major adverse cardiac event proceeds untested;¹^,2 ischemic heart disease and insulin-treated diabetes put him above it.
Then functional capacity: four METs or more, I proceed.² Two flights of stairs daily: he has passed that test at home.
Poor or unknown capacity: pharmacologic stress test, conditionally, only if the result would change the operation, the timing or my monitoring.¹
Continue beta-blocker and statin;² hold lisinopril 24 hours, because it is for controlled hypertension.²

Breaking down the answer

Urgency first — a ruptured viscus or a threatened limb has no time for a workup; I optimize what I can and plan an arterial line and postoperative troponins rather than cancel.
Active cardiac conditions stop the elective case — unstable angina, an acute coronary syndrome or MI within 60 days,² decompensated heart failure, high-grade block, symptomatic ventricular arrhythmia, severe symptomatic aortic stenosis: a mortality no monitoring offsets; cardiology first.
The RCRI — high-risk surgery, ischemic heart disease, heart failure, cerebrovascular disease, insulin-treated diabetes, creatinine above 2.0 mg/dL. The 2024 guideline names no single calculator; any validated one sorting low (<1%) from elevated (≥1%) risk.²
When the history is vague — the Duke Activity Status Index: a score above 34 marks low risk, and 4 METs remains the algorithm's cutoff for poor capacity.²
A test only if it changes management — routine stress testing is not recommended for low-risk patients, good functional capacity or low-risk surgery;¹ revascularization is done only when indicated independent of the operation,² so a positive test mostly changes monitoring and the surgical conversation.
Biomarkers — in elevated risk ACC/AHA prefers BNP or NT-proBNP (the ESC prefers troponin); normal (BNP <92 ng/L or NT-proBNP <300 ng/L, Canadian cutoffs) means low risk, no further testing;² elevated means troponins afterward.
Echocardiogram for a reason — new or worsening dyspnea, or known or suspected moderate-to-severe valve disease; not routinely for ventricular function in a stable, asymptomatic patient, and one within the past year need not be repeated.²

Follow-up question

Change the case: his preoperative workup finds a colon cancer, the hip is postponed, and he is now scheduled for open colectomy, which makes his RCRI 3. Worsening hip pain now stops him walking a block, and the surgeon wants to operate in two weeks. How does your plan change?

Follow-up answer

HeadlineTime-sensitive surgery, poor capacity, RCRI 3: I talk with the surgeon; a test must change the plan to earn its delay.

Time-sensitive now covers delays of up to 3 months (2024 guideline).² Pharmacologic stress testing only if he agrees to wait and the result alters the plan. Large reversible defect: cardiology; left main or three-vessel disease with an independent indication means revascularization, but a drug-eluting stent forces at least 3 months of dual antiplatelet therapy first, so the heart team weighs surgical revascularization or staging.² Small defect: arterial line, tight heart rate control, hemoglobin above 8 g/dL, daily troponins for 48 hours. If the cancer cannot wait: proceed, shared decision documented, high-risk care.

Pitfalls that cost points

Calling a 30-day-old MI an "old MI"; elective surgery waits 60 days.²
Starting a beta-blocker the night before surgery; the POISE trial showed more strokes and deaths.
Forgetting that delaying a cancer resection six weeks has its own mortality.

Rapid-fire

Q: Why four METs? A: Below that level the history cannot exclude ischemia, and the perioperative event rate roughly doubles; above it the heart has demonstrated reserve.

Q: Why not revascularize everyone with a positive test? A: The CARP trial showed no survival benefit from prophylactic revascularization before vascular surgery; the stent then adds dual antiplatelet therapy and a delay.

Q: Which patients get a 12-lead ECG? A: Anyone with known coronary disease, arrhythmia, peripheral vascular disease, cerebrovascular disease or structural heart disease having anything beyond a low-risk procedure; it provides a baseline, not a screen.

Q: When do you continue versus hold a long-standing beta-blocker? A: Always continue it; abrupt withdrawal causes rebound tachycardia and ischemia.² ACE inhibitors and ARBs for controlled hypertension are held 24 hours, but continued in heart failure with reduced ejection fraction.²

Numbers to know

Item	Value
Low-risk threshold	MACE <1% (RCRI 0–1)²
RCRI factors	6: high-risk surgery, CAD, CHF, CVA/TIA, insulin, Cr >2.0 mg/dL
Adequate functional capacity	≥4 METs or DASI >34²
Delay after MI, no intervention	60 days before elective surgery²
Beta-blocker start	≥8 days before surgery if newly indicated, never on the day of surgery²
SGLT2 inhibitors	Stop 3–4 days before surgery¹
Postoperative troponin surveillance	Consider in high-risk patients (e.g., at 24 and 48 h)

Sources

1.2024 AHA/ACC Perioperative CV Management Guideline: Key Points · American College of Cardiology, 2024 · acc.orgConfirms the 2024 guideline supersedes 2014; stress testing Class 3 for low risk, Class 2b for poor/unknown capacity with elevated risk.
2.2024 ACC/AHA guideline on perioperative cardiovascular management before noncardiac surgery: What's new? · Cleveland Clinic Journal of Medicine, 2025 · ccjm.orgCohn SL, CCJM 92(4), April 2025; primary guideline text (ahajournals/jacc) was not reachable from the fetcher.

Facts on this page were checked against these sources on Oct 14, 2026. Guidelines change; confirm doses against current institutional protocols.