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 with Cardiovascular Risk
Factors", Disease, or Symptoms
Scheduled for NCS

Patient with Cardiovascular Risk
Factors", Disease, or Symptoms
Scheduled for NCS

Patient with Cardiovascular Risk
Factors", Disease, or Symptoms
Scheduled for NCS

Patient with Cardiovascular Risk
Factors", Disease, or Symptoms
Scheduled for NCS

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Emergency surgery?

Emergency surgery?

Emergency surgery?

Proceed to surgery

Proceed to surgery

Proceed to surgery

Yes Yes

No

No

No

Proceed to surgery

Proceed to surgery

Proceed to surgery

Does the patient have?


Acute coronary syndrome
Unstable cardiac arrhythmias
Decompensated heart failure

 Does the patient have?


Acute coronary syndrome
Unstable cardiac arrhythmias
Decompensated heart failure


Acute coronary syndrome
Unstable cardiac arrhythmias
Decompensated heart failure


Acute coronary syndrome
Unstable cardiac arrhythmias
Decompensated heart failure

Yes

Yes

Yes

No

No

No

Management of acute cardiac
condition and multidisciplinary
team discussion for deferral of
surgery, noninvasive treatment,
or palliation

Management of acute cardiac
condition and multidisciplinary
team discussion for deferral of
surgery, noninvasive treatment,
or palliation

Management of acute cardiac
condition and multidisciplinary
team discussion for deferral of
surgery, noninvasive treatment,
or palliation





Risk calculator
for adverse cardiovascular
events (2a)

Estimation of perioperative risk
Does the patient have any of the following risk modifiers?


Severe valvular heart disease (Section 6.4)
Severe pulmonary hypertension (Section 6.3.2)
Elevated-risk congenital heart disease (Section 6.3.3)
Prior coronary stents/CABG (Sections 6.1.1 & 7.5)
Recent stroke (Section 6.7)
CIED (Pacemaker/CD) present (Section 6.6)
Frailty (Section 3.3)

 Risk calculator
for adverse cardiovascular
events (2a)

Estimation of perioperative risk
Does the patient have any of the following risk modifiers?


Severe valvular heart disease (Section 6.4)
Severe pulmonary hypertension (Section 6.3.2)
Elevated-risk congenital heart disease (Section 6.3.3)
Prior coronary stents/CABG (Sections 6.1.1 & 7.5)
Recent stroke (Section 6.7)
CIED (Pacemaker/CD) present (Section 6.6)
Frailty (Section 3.3)



Estimation of perioperative risk
any


Severe valvular heart disease (Section 6.4)
Severe pulmonary hypertension (Section 6.3.2)
Elevated-risk congenital heart disease (Section 6.3.3)
Prior coronary stents/CABG (Sections 6.1.1 & 7.5)
Recent stroke (Section 6.7)
CIED (Pacemaker/CD) present (Section 6.6)
Frailty (Section 3.3)


Severe valvular heart disease (Section 6.4)
Severe pulmonary hypertension (Section 6.3.2)
Elevated-risk congenital heart disease (Section 6.3.3)
Prior coronary stents/CABG (Sections 6.1.1 & 7.5)
Recent stroke (Section 6.7)
CIED (Pacemaker/CD) present (Section 6.6)
Frailty (Section 3.3)

Yes

Yes

Yes

No

No

No

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Consider 12-lead ECG in elevated-
risk asymptomatic patients without
established CVD (26) (Section 4.1)

Consider 12-lead ECG in elevated-
risk asymptomatic patients without
established CVD (26) (Section 4.1)

Consider 12-lead ECG in elevated-
risk asymptomatic patients without
established CVD (26) (Section 4.1)





Proceed to surgery

Proceed to surgery

Proceed to surgery

Poor or unknown functional capacity

(DASI $34, METS <4) (2a)

Poor or unknown functional capacity

(DASI $34, METS <4) (2a)

Poor or unknown functional capacity

(DASI $34, METS <4) (2a)

< Low calculated risk and no risk modifiers Low calculated Elevated calculated risk and no risk modifiers Elevated calculated Risk modifier present
with any calculated risk!

Consider appropriate team-based
consultation regarding timing of NCS
and perioperative diagnostic testing
and management 12-lead ECG is
reasonable in patients with established
CVD or
symptoms (2a) (Section 4.1)

Echocardiography for suspected
moderate/ severe valvular stenosis/
regurgitation, new dyspnea, or
suspected new/worsening ventricular
dysfunction(1/2a) (Sections 4.2, 6.4.1,
and 6.4.3)

Consider GDMT initiation for
long-term cardiovascular risk reduction
and disease management, as applicable
(Section 7)




















Risk modifier present

Proceed to surgery

Proceed to surgery

Proceed to surgery

Will further testing impact decision making/perioperative care?

Will further testing impact decision making/perioperative care?

Will further testing impact decision making/perioperative care?

No

No

No

Yes

Yes

Yes

Proceed to surgery or consider alternative
strategies: deferral of surgery, noninvasive
treatment, or palliation

Proceed to surgery or consider alternative
strategies: deferral of surgery, noninvasive
treatment, or palliation

Proceed to surgery or consider alternative
strategies: deferral of surgery, noninvasive
treatment, or palliation



No

No

No

Yes

Yes

Yes

Multidisciplinary team discussion regarding risks and benefits of additional cardiac evaluation

Multidisciplinary team discussion regarding risks and benefits of additional cardiac evaluation

Multidisciplinary team discussion regarding risks and benefits of additional cardiac evaluation

Proceed to surgery

Proceed to surgery

Proceed to surgery

Normal biomarker(s) Normal biomarker(s) Abnormal biomarker(s) Abnormal biomarker(s)

Consider alternative strategies: deferral
of surgery, noninvasive or invasive
treatment, or palliation or proceed
to surgery

Consider alternative strategies: deferral
of surgery, noninvasive or invasive
treatment, or palliation or proceed
to surgery

Consider alternative strategies: deferral
of surgery, noninvasive or invasive
treatment, or palliation or proceed
to surgery




Consider postoperative
troponin surveillance (2b)

Consider postoperative
troponin surveillance (2b)

Consider postoperative
troponin surveillance (2b)


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Proceed to surgery

Proceed to surgery

Proceed to surgery

Low-risk findings Low-risk findings Elevated-risk findings! Elevated-risk findings!

Consider GDMT initiation for long-
term cardiovascular risk reduction
and disease management, as applicable
(Section 7)

Consider GDMT initiation for long-
term cardiovascular risk reduction
and disease management, as applicable
(Section 7)

Consider GDMT initiation for long-
term cardiovascular risk reduction
and disease management, as applicable
(Section 7)




Pursue cardiac evaluation Pursue cardiac evaluation Defer additional cardiac evaluation Defer additional

Consider echocardiography
Considernoninvasive stress testing (2b)
Consider CCTA (2b)

Consider echocardiography
Considernoninvasive stress testing (2b)
Consider CCTA (2b)

Consider echocardiography
Considernoninvasive stress testing (2b)
Consider CCTA (2b)



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Preoperative biomarker risk assessment:

Preoperative biomarker risk assessment:

Preoperative biomarker risk assessment:

BNP/NT-proBNP (2a) BNP/NT-proBNP (2a) Consider troponin (2a) Consider troponin (2a)