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See also Chapter 3.

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 10–85). 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 kidney 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. In 2019, the American College of Surgeons published the risk of noncardiac surgery in heart patients based on their National Surgical Quality Improvement Program database. After analysis of almost 1.2 million patients, their multivariate risk features included age older than 75, history of heart disease, hemoglobin less than 12 mg/dL, vascular surgery, and emergency surgery. Each factor was assigned a point (total then 0, 1, 2, 3, greater than 3). An adverse outcome was noted in 0%, 0.5%, 2.0%, 5.6%, and 15.7% respectively.

eFigure 10–85.

American College of Cardiology/American Heart Association (ACC/AHA) stepwise approach to perioperative cardiac assessment for CAD. (Reproduced with permission from McKean SC, et ...

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