Stepwise Approach to Perioperative Cardiac Assessment for CAD from the Latest ACC/AHA Guidelines
Stepwise Approach to Perioperative Cardiac Assessment for CAD from the Latest ACC/AHA Guidelines - Flowchart Preoperative Cardiovascular Evaluation for Noncardiac Surgery Preoperative Cardiovascular Evaluation for Noncardiac Surgery
«Flowchart»

Patient scheduled for surgery with known or risk factors for CAD (Step 1)

Patient scheduled for surgery with known or risk factors for CAD (Step 1)

Patient scheduled for surgery with known or risk factors for CAD (Step 1)

Emergency

Emergency

Emergency

Clinical risk stratification and proceed to surgery

Clinical risk stratification and proceed to surgery

Clinical risk stratification and proceed to surgery

Yes

Yes

Yes

No

No

No

End

End

End

Evaluate and treat according to GDMT

Evaluate and treat according to GDMT

Evaluate and treat according to GDMT

Estimated perioperative risk of MACE based on combined clinical/surgical risk (Step 3)

Estimated perioperative risk of MACE based on combined clinical/surgical risk (Step 3)

Estimated perioperative risk of MACE based on combined clinical/surgical risk (Step 3)

ACS (Step 2)

ACS (Step 2)

ACS (Step 2)

Yes

Yes

Yes

No

No

No

No further testing (Class III:NB)

No further testing (Class III:NB)

No further testing (Class III:NB)

Low risk (<1%) (Step 4)

Low risk (<1%) (Step 4)

Low risk (<1%) (Step 4)

Elevated risk (Step 5)

Elevated risk (Step 5)

Elevated risk (Step 5)

Proceed to surgery

Proceed to surgery

Proceed to surgery

No further testing (Class IIa)

No further testing (Class IIa)

No further testing (Class IIa)

No further testing (Class IIb)

No further testing (Class IIb)

No further testing (Class IIb)

Moderate or greater (≥4 METs) functional capacity

Moderate or greater (≥4 METs) functional capacity

Moderate or greater (≥4 METs) functional capacity

≥

No or unknown

No or unknown

No or unknown

Excellent (>10 METs)

Excellent (>10 METs)

Excellent (>10 METs)

Moderate/Good (≥4-10 METs)

Moderate/Good (≥4-10 METs)

≥ Moderate/Good (≥4-10 METs) ≥

Coronary revascularization according to existing CPGs (Class I)

Coronary revascularization according to existing CPGs (Class I)

Coronary revascularization according to existing CPGs (Class I)

Proceed to surgery according to GDMT OR alternate strategies (noninvasive treatment, palliation) (Step 7)

Proceed to surgery according to GDMT OR alternate strategies (noninvasive treatment, palliation) (Step 7)

Proceed to surgery according to GDMT OR alternate strategies (noninvasive treatment, palliation) (Step 7)

OR

Pharmacologic stress testing (Class IIa)

Pharmacologic stress testing (Class IIa)

Pharmacologic stress testing (Class IIa)

If normal

If normal

If normal

If abnormal

If abnormal

If abnormal

Poor OR unknownfunctional capacity (<4 METs): Will further testing impact decision-making OR perioperative care? (Step 6)

Poor OR unknownfunctional capacity (<4 METs): Will further testing impact decision-making OR perioperative care? (Step 6)

Poor OR unknownfunctional capacity (<4 METs): Will further testing impact decision-making OR perioperative care? (Step 6)

OR OR

Yes

Yes

Yes

No

No

No

Proceed to surgery

Proceed to surgery

Proceed to surgery