Need for cardiac surgery?

Emergency surgery
Urgent or elective surgery

Proceed to the Operating Room.

Postoperative risk stratification and risk factor management.

Coronary revascularization within 5 years?

Yes
No

Recurrent symptoms or signs?

Yes
No

Recent coronary evaluation?

Yes
No

Recent coronary angiogram or stress test?

Favorable result and no change in symptoms
Unfavorable result or change in symptoms

Proceed to Operating Room

Clinical Predictors:

Major Clinical Predictors:
Unstable coronary symptoms

• Recent MI (< 1 month ago) with evidence of important ischemic risk by clinical symptoms or noninvasive study
• Unstable or severe angina (Canadian Cardiovascular Society Class III or IV)

Decompensated CHF
Significant arrhythmias

• High-grade atrioventricular block
• Symptomatic ventricular arrhythmias in the presence of underlying heart disease
• Supraventricular arrhythmias with uncontrolled ventricular rate

Severe valvular disease

Intermediate Clinical Predictors:
Mild angina pectoris (Canadian Cardiovascular Society Class I or II)
Prior MI (by history or pathological waves)
Compensated or prior CHF
Diabetes mellitus

Minor Clinical Predictors:
Advanced age
Abnormal EKG (LV hypertrophy, LBBB, ST-T abnormalities)
Rhythm other than sinus (eg. atrial fibrillation)
Low functional capacity (eg. unable to climb one flight of stairs with a bag of groceries)
History of stroke
Uncontrolled systemic hypertension

Consider delay or cancel noncardiac surgery Medical management and risk factor modification	Consider coronary angiography
Subsequent care dictated by findings and treatment results Subsequent care may include cancellation or delay of surgery, coronary revascularization followed by noncardiac surgery, or intensified care.

Intermediate Clinical Predictors

Functional Capacity:
Poor (< 4 METs)

• Can you take care of yourself?
• Eat, dress, or use the toilet?
• Walk indoors around the house?
• Walk a block or two on level ground at 2-3 mph or 3.2-4.8 km/h?
• Do light work around the house like dusting or washing dishes?

Moderate or excellent (> 4 METs)

• Climb a flight of stairs or walk up a hill?
• Walk on level ground at 4 mph or 6.4 km/h?
• Run a short distance?
• Do heavy work around the house like scrubbing floors or lifing or moving heavy furniture?
• Participate in moderate recreational activities like golf, bowling, dancing, doubles tennis, or throwing a baseball or football?
• Participate in strenuous sports like swimming, singles tennis, football, basketball, or skiing?

Surgical Risk:
High risk surgical procedure (Reported cardiac risk often >5%)

• Emergent major operations, particularly in the elderly
• Aortic and other major vascular
• Peripheral vascular
• Anticipated prolonged surgical procedures assoc with large fluid shifts and/or blood loss

Intermediate surgical risk procedure (Reported cardiac risk generally < 5%)

• Carotid endarterectomy
• Head and neck
• Intraperitoneal and intrathoracic
• Orthopedic
• Prostate

Low surgical risk procedure
(Reported cardiac risk generally < 1%, further preop cardiac testing not generally required)

• Endoscopic procedures
• Superficial procedures
• Cataract
• Breast

Results of Non-Invasive Testing:
Myocardial perfusion imaging or stress echocardiography

Low risk
High risk

Consider coronary angiography.

Subsequent care dictated by findings and treatment results
Subsequent care may include cancellation or delay of surgery, coronary revascularization followed by noncardiac surgery, or intensified care.

Minor Clinical Predictors

Functional Capacity:
Poor (< 4 METs)

• Can you take care of yourself?
• Eat, dress, or use the toilet?
• Walk indoors around the house?
• Walk a block or two on level ground at 2-3 mph or 3.2-4.8 km/h?
• Do light work around the house like dusting or washing dishes?

Moderate or excellent (> 4 METs)

• Climb a flight of stairs or walk up a hill?
• Walk on level ground at 4 mph or 6.4 km/h?
• Run a short distance?
• Do heavy work around the house like scrubbing floors or lifing or moving heavy furniture?
• Participate in moderate recreational activities like golf, bowling, dancing, doubles tennis, or throwing a baseball or football?
• Participate in strenuous sports like swimming, singles tennis, football, basketball, or skiing?

Minor Clinical Predictors

Surgical Risk:
Intermediate surgical risk procedure (Reported cardiac risk generally < 5%)

• Carotid endarterectomy
• Head and neck
• Intraperitoneal and intrathoracic
• Orthopedic
• Prostate

High risk surgical procedure

• Emergent major operations, particularly in the elderly
• Aortic and other major vascular
• Peripheral vascular
• Anticipated prolonged surgical procedures assoc with large fluid shifts and/or blood loss