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Gerontology, Palliative Care & Prevention · Topic 12 of 13

Perioperative Risk Assessment

Prevention · perioperative cardiovascular evaluation

Perioperative Risk Assessment

Test only when the result changes management: estimate risk, check functional capacity, then manage cardiac drugs and anticoagulants before surgery.

Key numbers
MACE risk ≥ 1% is elevatedMACE ≥ 1%
≥ 4 METs: proceed without testing≥ 4 METs
Normal BNP: no further cardiac testingBNP < 92 pg/mL
Stop SGLT2 inhibitors 3–4 days before3–4 days
Consider delay if BP ≥ 180/110≥ 180/110 mmHg
01 · Defined byMACE risk ≥ 1% is elevated

Estimate the risk of major adverse cardiac events with a validated tool (RCRI, NSQIP or others): < 1% is low risk — proceed to surgery without further testing; ≥ 1% is elevated risk.

02 · Defined by≥ 4 METs: proceed without testing

At elevated risk, functional capacity ≥ 4 METs — best judged with the Duke Activity Status Index (score > 34) — means proceed to surgery; < 4 METs or unknown capacity prompts further evaluation.

03 · The ruleStress test only if it changes management

Order stress testing only when the result would change management — not for low risk, low-risk surgery or good exercise capacity; revascularize only for usual indications (ACS, left main > 50%), never just for surgery.

01

The rules

Know these
Wait 12 months after a DES for ACSDelay elective surgery ≥ 12 months after a DES for ACS, ≥ 6 months after a DES for stable coronary disease and ≥ 14 days after angioplasty alone; stopping antiplatelets within 30 days of a stent is harmful.
02

Diagnosis & monitoring

Work-up
RCRI: six one-point risk factors must knowRCRI gives 1 point each for high-risk surgery (intraperitoneal, intrathoracic, suprainguinal vascular), ischemic heart disease, heart failure, cerebrovascular disease, preoperative insulin therapy and creatinine > 2 mg/dL.
Normal BNP: no further cardiac testingFor elevated risk with poor or unknown capacity, BNP or NT-proBNP (preferred by ACC/AHA) helps triage: BNP < 92 pg/mL or NT-proBNP < 300 pg/mL means low risk and no further cardiac testing.
Consider postoperative troponins in high-risk patientsThe 2024 guideline allows postoperative troponin surveillance in high-risk patients even without ischemic symptoms, to detect myocardial injury after noncardiac surgery.
Consider delay if BP ≥ 180/110Continue most antihypertensives; if BP is ≥ 180/110 mmHg before the day of elective surgery, consider delaying until controlled. Keep intraoperative MAP ≥ 60–65 mmHg and treat postoperative hypotension promptly.
03

Do right now

In this order
First moves
1
Treat active cardiac conditions before elective surgery
→
2
MACE risk ≥ 1% is elevatedMACE ≥ 1%
→
3
≥ 4 METs: proceed without testing≥ 4 METs
→
4
Normal BNP: no further cardiac testingBNP < 92 pg/mL
→
5
Stress test only if it changes management
Why each step
Treat active cardiac conditions before elective surgeryEmergency surgery (within 2 hours) proceeds without cardiac testing; postpone elective surgery for an active cardiac condition — ACS, decompensated heart failure or unstable arrhythmia — until it is evaluated and treated.
MACE risk ≥ 1% is elevatedEstimate the risk of major adverse cardiac events with a validated tool (RCRI, NSQIP or others): < 1% is low risk — proceed to surgery without further testing; ≥ 1% is elevated risk.
≥ 4 METs: proceed without testingAt elevated risk, functional capacity ≥ 4 METs — best judged with the Duke Activity Status Index (score > 34) — means proceed to surgery; < 4 METs or unknown capacity prompts further evaluation.
Normal BNP: no further cardiac testingFor elevated risk with poor or unknown capacity, BNP or NT-proBNP (preferred by ACC/AHA) helps triage: BNP < 92 pg/mL or NT-proBNP < 300 pg/mL means low risk and no further cardiac testing.
Stress test only if it changes managementOrder stress testing only when the result would change management — not for low risk, low-risk surgery or good exercise capacity; revascularize only for usual indications (ACS, left main > 50%), never just for surgery.
04

Management

Orders
Never start a beta-blocker on surgery dayContinue chronic beta-blockers; if newly indicated, start at least 8 days before surgery to assess tolerance — never on the day of surgery. Do not start clonidine preoperatively, but continue it if already taken.
Hold ACE inhibitor/ARB 24 h; continue statinsFor controlled hypertension, holding an ACE inhibitor or ARB 24 hours before surgery limits intraoperative hypotension; continue it in HFrEF. Continue statins, and start one when otherwise indicated.
Stop SGLT2 inhibitors 3–4 days beforeStop SGLT2 inhibitors 3–4 days before surgery (4 days for ertugliflozin) to prevent euglycemic ketoacidosis; continue the rest of heart failure therapy.
Continue aspirin in patients with stentsContinue aspirin perioperatively in patients with coronary stents when bleeding risk allows. If a P2Y12 inhibitor must stop: clopidogrel 5 days, ticagrelor 3 days and prasugrel 7 days before surgery.
Stop warfarin 5 days; usually no bridgingStop warfarin 5 days before surgery; resume within 24 hours. Most patients need no bridging (BRIDGE: less bleeding); bridge only high thrombotic risk — mechanical mitral valve, recent LV thrombus, AF with recent stroke.
Hold a DOAC 1–2 days; never bridgeOmit apixaban, rivaroxaban or dabigatran 1 day before low-bleeding-risk and 2 days before high-bleeding-risk surgery (longer for dabigatran with low CrCl); resume 1 day after, or 2–3 days after high-risk surgery — no bridging.
05

Stopping warfarin or a DOAC before surgery

Commonly confused
Last dose5 days before surgery
BridgingNot for most (BRIDGE); only high thrombotic risk
RestartWithin 24 hours after the procedure
Key trialBRIDGE (AF)
06

More detail

Reference
Show 8 reference facts
2024 timing definitions: emergency surgery < 2 hours, urgent 2–24 hours, time-sensitive up to 3 months, and elective — can be delayed indefinitely.
Risk modifiers that calculators miss: severe valve disease (especially aortic stenosis), pulmonary hypertension, congenital heart disease, prior PCI or CABG, recent stroke, a cardiac implantable device and frailty.
Get an echocardiogram for new or worsening dyspnea or known or suspected moderate–severe valve disease without one in the past year — not to screen LV function in stable patients without symptoms.
Stop aspirin taken for primary prevention (except before carotid surgery); continue secondary-prevention aspirin when cardiac risk outweighs bleeding risk; do not start aspirin just for surgery.
Time-sensitive surgery may proceed ≥ 3 months after a DES when delay is riskier than perioperative MACE; continue DAPT if surgery falls within 30 days of a bare-metal stent or 3 months of a DES.
If a patient with a prior stent takes oral anticoagulant monotherapy that must stop before surgery, consider substituting aspirin until the anticoagulant resumes.
Clinicians’ subjective estimate of METs predicts poorly; a structured questionnaire (DASI) does, and a patient’s self-reported inability to climb 2 flights of stairs is linked to more cardiac complications and death.
GLP-1 receptor agonists: most patients continue them before elective surgery; defer surgery during dose escalation or with GI symptoms, and use a 24-hour liquid diet for those at highest risk of retained gastric contents.
Pearl

A patient with good functional capacity — at least 4 METs — usually goes to surgery without a stress test.

Sources · Cohn SL. 2024 ACC/AHA guideline on perioperative cardiovascular management before noncardiac surgery: What's new? Cleve Clin J Med 2025;92:213–219 (summarizes Thompson A et al., 2024 AHA/ACC perioperative guideline) · Merck Manual Professional — Preoperative Evaluation · MDCalc — Updated review of the Revised Cardiac Risk Index for preoperative risk · Thompson A et al. 2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM Guideline for Perioperative Cardiovascular Management for Noncardiac Surgery. J Am Coll Cardiol 2024;84:1869–1969 · Douketis JD et al. Perioperative Bridging Anticoagulation in Patients with Atrial Fibrillation (BRIDGE). N Engl J Med 2015;373:823–833 (abstract via Europe PMC) · Douketis JD et al. Perioperative Management of Antithrombotic Therapy: An ACCP Clinical Practice Guideline. Chest 2022 (abstract: strong recommendation against bridging in AF) · Douketis JD et al. Perioperative Management of Patients With Atrial Fibrillation Receiving a DOAC (PAUSE). JAMA Intern Med 2019;179:1469–1478 · ACC — 2024 AHA/ACC Perioperative CV Management Guideline: Key Points (Ten Points to Remember, Sept 2024) · ASA news release — Multi-society clinical practice guidance on GLP-1 receptor agonists before surgery (ASA/AGA/ASMBS/ISPCOP/SAGES, Oct 2024; Kindel TL et al. Surg Obes Relat Dis 2025) · Starter sheet built from the verified AGACNP fact map (facts reviewed 2026-10-15).