Preoperative Evaluation of the Noncardiac Surgical Patient

BASICS

Purpose: Detect established or occult disease/factors that may increase perioperative risk.
Goals:
Thorough medical history & physical exam to direct further testing/consultation
Recommend strategies to reduce risk/optimize condition before surgery
Encourage health optimization for better perioperative and long-term outcomes

Major adverse cardiovascular/cerebrovascular event (MACCE) rates post-surgery are decreasing (3.1% in 2004 to 2.6% in 2013).
Perioperative acute MI and death have decreased, but ischemic stroke rates increased.
Proper preoperative assessment and optimization lowers morbidity/mortality.

Functional Capacity: Most important determinant of cardiac risk.
<4 METs (can’t climb stairs or walk up hill) = ↑ cardiac risk.
Duke Activity Status Index or similar structured tools are better than subjective assessment.
Surgical Risk:
Intrathoracic, intra-abdominal, suprainguinal vascular procedures carry highest risk for major adverse cardiac events (MACE).
Clinical Risk Factors:
History of ischemic heart disease, compensated heart failure, prior CHF, cerebrovascular disease, diabetes, renal insufficiency.
Age: >70 years increases perioperative complication/mortality risk (mostly due to comorbidities, not age itself).

Vitals (BP bilaterally), carotids (bruits), heart (rhythm, murmurs), lungs (rales, wheezes)
If considering regional anesthesia: focused neuro exam

Labs: Not routine; order only for specific indications or risk factors. Labs in past 4 months valid unless clinical change.
CBC: Anemia, age extremes, liver/kidney disease, expected major blood loss
WBC/Platelets: Bleeding/myeloproliferative disorders, chemotherapy
Chemistry (electrolytes, glucose, renal/liver fx): Age extremes, CHF, renal/liver/endocrine disorders, diuretic/nephrotoxic drugs
Coags (PT/PTT): Bleeding hx, liver dz, malnutrition, abx/anticoagulants
Urinalysis: Not routinely recommended
Pregnancy test: Consider in all women of childbearing age
CXR: Only if known/suspected heart or lung disease or recent symptom change
ECG:
Only if coronary disease, PVD, significant arrhythmia, structural heart disease, or symptoms; NOT for all patients.
Echo:
Only if unexplained dyspnea, worsening CHF, or moderate-severe valve disease not recently evaluated.
PFTs:
Only for thoracic surgery or unexplained dyspnea.
Risk Tools: Use Revised Cardiac Risk Index or ACS NSQIP online risk calculator.
If MACE risk <1%: proceed
If >1%: assess METs; <4 METs/unknown → consider stress test if will change management

Frailty assessment/interventions may reduce morbidity/mortality.
No test is routine. All testing should be tailored to the individual’s comorbidities and surgical risk.
Active cardiac conditions = delay or cancel surgery.

Preoperative evaluation = record review, interview, and physical exam.
Functional capacity, surgical risk, and clinical risk factors determine further cardiac workup.
Active cardiac conditions → defer nonemergent surgery.
No routine pre-op testing. Tailor to patient.