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Perioperative cardiac risk management for noncardiac surgery

Key sources
The following summarized guidelines for the evaluation and management of perioperative cardiac risk management for noncardiac surgery are prepared by our editorial team based on guidelines from the European Society of Anaesthesiology and Intensive Care (ESAIC 2023), the European Society for Vascular Surgery (ESVS 2023), the European Society of Cardiology (ESC 2023; 2022; 2021), the American College of Chest Physicians (ACCP 2022), the Society for Cardiovascular Angiography and Interventions (SCAI/AHA/ACC 2022), the American Heart Association (AHA/ACC 2021; 2014), and the Canadian Cardiovascular Society (CCS 2016).


1.Classification and risk stratification

Cardiac risk stratification: as per ESC 2022 guidelines, obtain preoperative risk assessment, ideally at the same time as the NCS is proposed.
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2.Diagnostic investigations

History and physical examination: elicit an accurate history and obtain a clinical assessment in all patients scheduled for NCS.
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  • ECG (low-risk patients)

  • ECG (high-risk patients)

  • Cardiac biomarkers

  • Echocardiography

  • Exercise stress testing

  • Pharmacological stress testing

  • Coronary CTA

  • Hemoglobin levels

3.Diagnostic procedures

Coronary angiography: as per ESC 2022 guidelines, use the same indications for invasive coronary angiography and revascularization preoperatively as in the non-surgical setting.
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4.Medical management

General principles: optimize guideline-recommended treatment of CVD and cardiovascular risk factors before NCS if time allows.
control cardiovascular risk factors, including BP, dyslipidemia, and diabetes, before NCS.

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  • Management of beta-blockers

  • Management of RAAS inhibitors

  • Management of statins

  • Management of antiplatelets

  • Management of anticoagulants (VKAs, elective surgeries/procedures)

  • Management of anticoagulants (VKAs, minor procedures)

  • Management of anticoagulants (heparins)

  • Management of anticoagulants (DOACs)

  • Management of diuretics

  • Management of SGLT-2 inhibitors

  • Prophylactic beta-blockers

  • Prophylactic alpha-2 agonists

  • Prophylactic CCBs

  • Prophylactic statins

  • Prophylactic aspirin

  • Prophylactic nitroglycerin

5.Nonpharmacologic interventions

Smoking cessation: as per ESC 2022 guidelines, advise smoking cessation > 4 weeks before NCS to reduce postoperative complications and mortality.

6.Therapeutic procedures

Coronary revascularization: as per ESC 2022 guidelines, consider obtaining preoperative evaluation in patients with an indication for PCI by an expert team (surgeon and cardiologist) before elective NCS.
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  • Pulmonary artery catheterization

  • Hemodynamic assist devices

7.Perioperative care

Choice of anesthesia: consider administering either a volatile anesthetic agent or total IV anesthesia in patients undergoing NCS, with the choice determined by factors other than the prevention of myocardial ischemia and myocardial infarction.

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  • Hemodynamic monitoring

  • BP control

  • Body temperature control

  • Thromboprophylaxis

  • Bleeding control

  • Pain management

8.Surgical interventions

Choice of surgical approach: consider using endovascular or video-assisted approaches in patients with high cardiovascular risk undergoing vascular or pulmonary surgery.

9.Specific circumstances

Patients with obesity
Assess cardiorespiratory fitness to estimate perioperative cardiovascular risk in patients with obesity, with particular attention to patients undergoing intermediate- and high-risk NCS.
Consider obtaining additional specialist assessment before major elective NCS in patients at high risk of obesity hypoventilation syndrome.

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  • Patients with diabetes mellitus

  • Patients with renal impairment

  • Patients with AAA

  • Patients with carotid artery disease (preoperative evaluation)

  • Patients with carotid artery disease (timing of surgery)

  • Patients with carotid artery disease (preoperative statins and antithrombotics)

  • Patients with carotid artery disease (carotid revascularization)

  • Patients with PAD

  • Patients with VHD (general principles)

  • Patients with VHD (aortic stenosis)

  • Patients with VHD (MS)

  • Patients with VHD (AR)

  • Patients with VHD (MR)

  • Patients with cardiomyopathy

  • Patients with ACS

  • Patients after PCI

  • Patients with supraventricular arrhythmias

  • Patients with ventricular arrhythmias

  • Patients with cardiac implantable electronic devices

  • Patients with pericardial diseases

  • Patients with adult congenital heart disease

  • Patients with patent foramen ovale

  • Patients with pulmonary hypertension

10.Patient education

General counseling
As per ESC 2022 guidelines:
Provide patients with individualized instructions for preoperative and postoperative changes in medications, in verbal and written formats with clear and concise directions.
Consider providing a structured information list (such as a checklist to help with common issues) in patients with CVD or at high risk of cardiovascular complications scheduled for NCS.

11.Follow-up and surveillance

Postoperative cardiac monitoring, general principles
Ensure high awareness of perioperative cardiovascular complications and obtain surveillance for perioperative myocardial infarction in patients undergoing intermediate- or high-risk NCS.
Obtain systematic perioperative myocardial infarction evaluation to identify the underlying pathophysiology and define therapy.

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  • Postoperative cardiac monitoring (ECG)

  • Postoperative cardiac monitoring (troponin)

  • Management of postoperative complications (myocardial injury/ischemia)

  • Management of postoperative complications (arrhythmias)

  • Management of postoperative complications (PE)