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See also Chapter 3-04.

There are guidelines to help the clinician and patient better define the risk of both cardiac and noncardiac surgery in heart patients. The easiest to use algorithms for cardiac surgery can be found on either of two websites: one includes the euroSCORE ( and the other the STS (Society of Thoracic Surgeons) database that provides a longitudinal look at the risk of cardiac surgery ( The EuroScore method invariably results in a greater risk score than the STS. These preoperative guidelines and algorithms are also available as smartphone applications (preop cardiac evaluation, STS scoring system, ACC/AHA risk of noncardiac surgery algorithm).

The assessment of the risk of noncardiac surgery in cardiac patients is addressed by the 2014 ACC/AHA Task Force which provides clinically useful algorithms to help determine risk including the controversy surrounding beta-blocker prophylaxis. The major cardiovascular societies have also outlined an approach to assessing risk for cardiac patients that need noncardiac surgery. It basically follows a stepwise approach that assesses the clinical status of the patient and combines that with the inherent risk of the surgical procedure (eFigure 10–102). There are societies that have provided multivariate risk models. The Revised Cardiac Risk Index (RCRI) is most commonly used and is available as a smartphone or computer application. Others include the American College of Surgeons National Quality Improvement Program (NSQIP), Myocardial Infarction and Cardiac Arrest calculator, and the American College of Surgeons NSQIP Surgical Risk Calculator. Each of these can be found on-line to address an individual patient risk. The RCRI takes into account the risk of the noncardiac surgery, the status or presence of ischemic heart disease, the history of heart failure, the history of cerebrovascular disease, the preoperative need for insulin, and renal function. In 2017, the Canadian Cardiovascular Society published their own interpretation of prior guidelines and made a variety of new suggestions regarding the assessment of cardiovascular patients prior to noncardiac surgery. Some of the suggestions from the Canadian Cardiovascular Society included measuring the NT-proBNP or BNP prior to surgery and troponin levels after, avoiding most cardiovascular testing prior to noncardiac surgery, against perioperative use of aspirin or beta-blockers and in favor of withholding ARBs or ACE inhibitors prior to the surgery. Details can be found online.

eFigure 10–102.

Stepwise approach to assessing cardiac patient risk for noncardiac surgery. (Reproduced, with permission, from Fleisher LA et al. ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery) Developed in Collaboration With the American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, and Society for Vascular Surgery. J Am Coll Cardiol. 2007 ...

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