Perioperative cardiac assessment

• Perioperative cardiac assessment is not a test; it is a structured evaluation that weighs the risk of the operation against the risk of the patient's heart, then decides who needs optimisation, monitoring or a change in the surgical plan.
• Most patients do not need a preoperative electrocardiogram, echocardiogram or stress test. Testing is reserved for situations in which a result would change management.
• The two reference guideline editions are the 2024 American Heart Association/American College of Cardiology (AHA/ACC) guideline on perioperative cardiovascular management for noncardiac surgery, and the 2022 European Society of Cardiology (ESC) guideline on cardiovascular assessment and management of patients undergoing non-cardiac surgery.
• Functional capacity is a powerful predictor. A patient unable to reach 4 metabolic equivalents (METs), roughly one flight of stairs, is at clearly increased perioperative risk.
• The Revised Cardiac Risk Index (RCRI) turns six common clinical factors into a score: 0 is low risk, 1 is low-to-intermediate risk, and 2 or more indicate elevated risk. ^[3]
• Cardiac drugs follow stable rules: continue beta-blockers and statins, do not start a beta-blocker within about a week of surgery, hold angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs) on the morning of surgery when hypotension is a concern, and time any interruption of antiplatelet drugs against bleeding and stent thrombosis risk.

By the end of this page you should be able to:

1. Apply the 2024 AHA/ACC and 2022 ESC stepwise approach to a patient facing non-cardiac surgery.
2. Calculate and interpret the Revised Cardiac Risk Index and use at least one alternative risk calculator.
3. Assess functional capacity with METs and the Duke Activity Status Index, and know when functional capacity is poor.
4. Decide when a preoperative electrocardiogram, transthoracic echocardiogram, stress test, coronary computed tomography or cardiac biomarker is appropriate.
5. Manage beta-blockers, statins, ACE inhibitors or ARBs, calcium channel blockers, antiplatelet and anticoagulant drugs around non-cardiac surgery.
6. Recognise active cardiac conditions, heart failure, valvular disease and a recent myocardial infarction that must be addressed before elective surgery, and plan postoperative surveillance.

This page concerns the assessment of cardiovascular risk before and during non-cardiac surgery in adults. It is written for medical students and junior clinicians, following the two newest widely available guideline editions: the 2024 AHA/ACC guideline on perioperative cardiovascular management for noncardiac surgery and the 2022 ESC guideline on cardiovascular assessment and management of patients undergoing non-cardiac surgery. ^{[2] [4]} These documents agree on the central themes: systematic risk stratification, avoidance of routine low-yield testing, optimisation of medical therapy, and close observation during and after the operation.

The scope is deliberately limited. It does not cover the preoperative assessment of cardiac surgery, or the conduct of cardiopulmonary bypass. It does not replace anaesthetic, cardiology or surgical judgement for a particular patient: a guideline provides a framework, and individual decisions require nuance, especially when the operation is urgent. ^[2]

Cardiovascular complications remain a leading cause of death after surgery. Major adverse cardiovascular events occur in roughly 1 to 5 percent of patients undergoing major noncardiac surgery, and about half of all deaths within 30 days of noncardiac surgery are cardiovascular in origin. ^[3] Major perioperative events are reported in 3 percent of patients undergoing inpatient noncardiac surgery, and around 1.5 percent die within 30 days. ^{[2] [1]}

A cardiac assessment of this kind is indicated for any adult in whom intermediate- or high-risk non-cardiac surgery is proposed and who has, or is suspected to have, cardiovascular disease, cardiovascular risk factors, or limited exercise tolerance. ^{[2] [3]} Assessment is also appropriate whenever a new or worsening cardiac symptom is reported, a murmur is heard, or there is a history of coronary artery disease, heart failure, significant arrhythmia, cerebrovascular disease, peripheral artery disease or impaired renal function. ^{[2] [3]}

Young, fit patients undergoing low-risk surgery do not need a cardiac work-up beyond a routine history, examination and standard safety checks. ^[2]

There is no contraindication to taking a history, examining the patient and calculating a risk score. What both guidelines discourage explicitly is routine cardiac testing in asymptomatic patients with good functional capacity who are undergoing low-risk surgery. ^{[1] [2]}

Two situations modify the plan:

• Active cardiac conditions (unstable angina, acute heart failure, significant or unstable arrhythmia, symptomatic severe valvular disease) should be stabilised or treated first, and elective surgery postponed by days to weeks. ^{[3] [2]}
• Emergency surgery proceeds without completing cardiac evaluation; assessment happens in parallel with resuscitation. ^{[2] [3]}

No special anatomy beyond a knowledge of the cardiac chambers, valves and coronary territories is needed for this assessment. The equipment available in most clinics is sufficient: sphygmomanometer, stethoscope, electrocardiograph, and access to transthoracic echocardiography, laboratory biomarker assays (troponin and BNP or NT-proBNP), and, where indicated, cardiac imaging or stress testing.

Preparation means time. For elective or time-sensitive surgery, the assessment should be completed early enough to allow optimisation: anaemia corrected, blood pressure controlled, glucose adjusted, medicines planned, and a cardiology opinion obtained when needed.

When discussing risk, three elements should be established and documented: ^[2]

• The surgical risk, graded as low (under 1 percent), intermediate (1 to 5 percent) or high (over 5 percent) 30-day cardiac event risk of the procedure itself. ^{[1] [3]}
• The patient's risk profile, from the cardiac risk index, functional capacity, frailty and comorbidities. ^[2]
• A clear plan: proceed, optimise and proceed, proceed with monitoring, or postpone. ^[3]

Consent for surgery in higher-risk patients should include the possibility of perioperative myocardial injury, arrhythmia and the need for postoperative monitoring. Where risk is significant, these conversations belong to the preoperative clinic rather than the day of surgery, and shared decision-making incorporates the patient's preferences. ^[2]

Begin with a focused history that asks about angina, breathlessness, palpitations, syncope, ankle swelling and exercise limitation, and about prior cardiovascular events. Ask specifically about functional limitation: can the patient walk on the flat, climb a flight of stairs, carry out self-care activities at home? ^[2] Take blood pressure and heart rate, and examine the precordium, lung fields and peripheral pulses. A newly discovered murmur, an S3 gallop or a raised jugular venous pressure is not a screening finding to be ignored; it directs specific investigation, and these patients should proceed to imaging. ^[2]

The search for cardiovascular disease should include symptoms suggestive of ischaemia even when mild, because perioperative myocardial infarction is often silent: more than 80 percent of patients with a perioperative myocardial infarction do not experience chest pain. ^[3]

The Revised Cardiac Risk Index is a simple six-item score derived from a large prospective study of non-cardiac surgery. One point is given for each of six factors. ^{[1] [3]}

A score of 2 or more marks elevated risk of major cardiac complications. ^[3] The RCRI has limitations in modern populations (it may underestimate risk in some patients), but it remains the common bedside screen and is endorsed by the AHA/ACC and ESC.

Other tools are used alongside or instead of it. The National Surgical Quality Improvement Program (NSQIP) surgical risk calculator, the Myocardial Infarction or Cardiac Arrest (MICA or Gupta) calculator, the American College of Surgeons surgical risk calculator, the AUB-HAS2 score and frailty scales such as the Clinical Frailty Scale predict wider outcomes, including pulmonary, renal and delirium complications, and are more informative in older or complex patients. ^{[1] [3]} The choice of tool is less important than using one consistently: the 2024 AHA/ACC guideline does not mandate a particular calculator. ^[2]

Frailty is itself a powerful multiplier. A meta-analysis of 1.1 million adults showed frailty significantly raises postoperative complications (relative risk 2.39, 95 percent confidence interval 2.02 to 2.83) and mortality (relative risk 3.71, 95 percent confidence interval 2.89 to 4.77). ^{[1] [3]} The Brazilian 2024 guideline gives a Class I recommendation for functional capacity assessment in intermediate- or high-risk surgery and a Class IIa recommendation that frailty be assessed routinely in older patients facing intermediate- or high-risk operations. ^[4]

Cardiac risk depends on the operation as well as the patient. ^{[2] [3]}

Functional capacity is one of the strongest predictors of perioperative events and reflects cardiac reserve better than many biomarkers. It is expressed in metabolic equivalents (METs): one MET is resting oxygen consumption. ^{[1] [2]}

The traditional screen is a simple history: patients who can climb roughly one flight of stairs without symptoms are generally considered to have adequate capacity. Patients below 4 METs are at increased perioperative risk, and a self-reported inability to climb two flights of stairs has also been associated with increased postoperative cardiac complications and death. ^{[1] [2]} Self-reported METs are unreliable, because patients and clinicians overestimate capacity; asking about specific tasks is better than asking for a number.

The 12-item Duke Activity Status Index is more accurate and correlates with peak oxygen uptake. It is scored from 0 to 58, and a score under 34 indicates an increased risk of 30-day death or myocardial infarction. ^{[1] [2] [3]} Using DASI together with RCRI adds predictive value beyond either alone. ^[2] The 2024 AHA/ACC guideline gives a Class IIa recommendation for using DASI as a more robust measure than self-reported METs. ^[1] An alternative cutoff of 25 points may be acceptable when the aim is to reduce unnecessary stress testing, at the cost of accepting a slightly higher complication rate. ^[2]

Neither major guideline recommends routine preoperative cardiac testing in unselected patients. ^{[1] [2]} Testing is chosen when a result will change management, corroborated by the clinical picture and the risk stratification above. ^[2]

A baseline electrocardiogram (ECG) is not needed for low-risk surgery in an asymptomatic patient without cardiovascular disease; neither the AHA/ACC nor the Brazilian 2024 guideline recommends it in that setting. ^{[1] [2] [4]} For intermediate- or high-risk surgery, use is more liberal. The Brazilian Society of Cardiology 2024 guideline attributes Class I evidence for obtaining an ECG in patients undergoing intermediate- or high-risk surgery and in those with intermediate or high perioperative cardiovascular event risk estimated from clinical algorithms. ^[4] Murthy and colleagues summarise the 2024 AHA/ACC stance as a Class IIb recommendation even in asymptomatic patients without cardiovascular disease undergoing high-risk surgery. ^[1]

New but stable findings (old Q waves, bundle branch block) do not need further preoperative evaluation; new atrial fibrillation, high-grade atrioventricular block, prolonged QT interval or dynamic ischaemic change should be addressed before surgery proceeds. ^[2]

Routine preoperative echocardiography is not recommended in asymptomatic patients. ^{[1] [2]} Indications include:

• Signs or symptoms of new or worsening heart failure. ^[2]
• A new murmur, in particular if symptomatic, or an unexamined murmur before higher-risk surgery. ^[2]
• Suspected valvular disease detected clinically. ^[2]
• A family history of genetic cardiomyopathy, before any non-cardiac surgery (ESC Class I). ^[2]
• Poor or unknown functional capacity before high-risk surgery (ESC Class I; before intermediate-risk surgery Class IIb). ^[2]
• Known cardiac dysfunction where a recent echocardiogram is unavailable or the clinical picture has changed (AHA/ACC Class IIa). ^[2]

Stable, mild-to-moderate valvular disease that has been echocardiography-confirmed within the last 12 months does not require repeat imaging in a patient with no new symptoms. ^[2]

The 2022 ESC guideline is somewhat more liberal in its recommendations for transthoracic echocardiography and stress testing than the AHA/ACC, while the AHA/ACC approach is comparatively restrictive. ^[2]

Routine stress testing is not recommended for patients with good functional capacity (4 METs or more) or undergoing low-risk surgery. ^{[1] [2]} Stress imaging (exercise ECG, stress echocardiography, nuclear perfusion) or coronary CT angiography may be considered (AHA/ACC Class IIb) when functional capacity is poor or unknown, the surgery is intermediate or high risk and the risk profile is elevated. ^{[1] [2]} Moderate-to-severe inducible ischaemia should trigger a team discussion rather than an automatic operation: prophylactic revascularisation has not been shown to improve outcome. The coronary artery revascularisation prophylaxis (CARP) trial showed routine preoperative stenting or bypass in stable patients did not reduce events compared with optimal medical therapy. ^{[2] [3]} Revascularisation is reserved for patients meeting standard cardiology indications, such as acute coronary syndrome or significant left main or severe multivessel disease, independent of the operation. ^{[3] [4]}

The Brazilian 2024 guideline allows exercise testing, with imaging stress (Class IIa), and exercise ECG (Class IIb), in patients with poor functional capacity and elevated risk where a result would change management. ^[4] New to the 2024 AHA/ACC guideline, coronary CT angiography is listed as an alternative to pharmacological stress testing. Its high negative predictive value can clear a patient with a coronary artery calcium score of 0 within the preceding 2 years, but it is prone to overestimating risk compared with clinical scores alone. ^[1]

Natriuretic peptides (BNP, NT-proBNP) and cardiac troponin reflect myocardial wall stress and injury and are strong predictors of perioperative major cardiac events. ^{[1] [3]}

Low-risk patients and patients undergoing low-risk surgery do not need biomarker testing and should proceed. ^[1] In elevated-risk patients, combining the RCRI score with natriuretic peptides or troponin improves discrimination over clinical indices alone, and a negative biomarker in an otherwise elevated-risk patient supports proceeding without further testing, because of the good negative predictive value. ^{[1] [3]}

The 2024 AHA/ACC guideline prefers BNP or NT-proBNP, while the ESC guideline prefers troponin. ^[2] Normal values cited in this context are BNP below 92 ng/L, NT-proBNP below 300 ng/L, or troponin at or under the 99th percentile, as per the Canadian Cardiovascular Society guidelines. ^[2]

Observed NT-proBNP thresholds also support risk stratification: below 100 pg/mL suggests low risk, 100 to 299 pg/mL intermediate risk, and 300 pg/mL or more high risk of 30-day cardiac complications. ^[3] The 2017 Canadian guidelines recommended NT-proBNP measurement before surgery in patients aged 65 years or older, or 45 to 64 years old with significant cardiovascular risk factors, to guide the intensity of perioperative monitoring. ^[3] The Brazilian 2024 guideline gives a Class I recommendation for natriuretic peptide testing in patients aged over 65 years, or aged 45 to 64 years with cardiovascular disease or risk factors. ^[4]

An elevated troponin or natriuretic peptide should lead to risk reclassification and shared decision-making about proceeding, rather than to automatic cancellation or revascularisation, because no study shows a mortality benefit from changing management on an abnormal biomarker alone. ^[1]

Cardiac drug management is as important as testing.

Continue beta-blockers throughout the perioperative period in patients already taking them; withdrawal can cause rebound tachycardia and hypertension. ^{[2] [3] [4]}

Starting a beta-blocker de novo is a different matter. High-dose beta-blockade initiated immediately before surgery, as studied in POISE, increased stroke and caused dangerous bradycardia and hypotension. ^[3] Current best practice is to restrict initiation to carefully selected high-risk patients (for example those with several RCRI risk factors or inducible ischaemia on testing), starting weeks before surgery at low dose and slowly up-titrating to a target heart rate. ^{[2] [3]} Initiation of a beta-blocker within 7 days of surgery is to be avoided; where a new indication exists, start at least 8 days before the operation, so tolerability and dose titration can be assessed. ^{[2] [3]} A 2018 Cochrane review found that perioperative beta-blockers reduce nonfatal myocardial infarction by about 27 percent and atrial fibrillation by about 60 percent, but increase stroke and hypotension, with no consistent mortality benefit. ^[2]

Continue chronic statin therapy, and initiate a statin in statin-naive patients undergoing elevated-risk surgery (especially vascular surgery) or who have an independent indication (known coronary artery disease, cerebrovascular or peripheral artery disease, diabetes, hyperlipidaemia, or high 10-year cardiovascular risk). ^{[2] [3] [4]} Statins are used for their plaque-stabilising and anti-inflammatory effects as well as for lipid lowering. Ideally a statin should be started a few weeks before surgery; last-minute high-dose loading, as studied in LOAD, has not consistently reduced cardiac events. ^{[2] [3]}

Long-term ACE inhibitor or ARB therapy (for example in heart failure or hypertension) should usually be continued, but these agents are commonly held on the morning of surgery to reduce intraoperative hypotension. ^{[2] [3] [4]} Where control of renin-angiotensin blockade matters, such as heart failure with reduced ejection fraction, continuation may be appropriate. ^[2] The Brazilian 2024 guideline permits maintenance with selective suspension in appropriate patients. ^[4]

Chronic calcium channel blockers, diuretics and clonidine are usually maintained, with selective suspension allowed; clonidine should not be started newly before surgery and, if already taken, should be continued to avoid rebound hypertension. ^{[2] [4]} Sodium-glucose cotransporter-2 (SGLT2) inhibitors should be withheld for 3 to 4 days before surgery (4 days for ertugliflozin) to reduce the risk of perioperative metabolic acidosis. ^[2]

Aspirin given for secondary prevention should be continued for most operations, with exceptions for surgery at very high bleeding risk (neurosurgery, and certain ophthalmic, spinal or prostate procedures). ^{[2] [3]} Aspirin given for primary prevention should be discontinued before surgery, and initiation of aspirin preoperatively is not indicated. ^[2]

Dual antiplatelet therapy and anticoagulants are managed by balancing bleeding against thrombosis risk, including the risk of stent thrombosis after recent coronary stenting. ^{[2] [3]} Where antiplatelet drugs must be stopped, timing from the 2024 AHA/ACC guidance is: prasugrel 7 days before, clopidogrel 5 days before, ticagrelor 3 days before, and aspirin 4 to 5 days before the procedure; ticagrelor is the only reversible platelet inhibitor in this group. ^[2]

When a recent stent is present, cardiology and surgery should jointly decide the timing of the operation and the antiplatelet plan. ^[2]

The 2024 AHA/ACC and 2022 ESC guidance agree on longer waiting times and a shorter window for selected cases:

• After balloon angioplasty without a stent: delay noncardiac surgery for at least 14 days. ^[2]
• After drug-eluting stent placement for acute coronary syndrome: delay elective surgery for at least 12 months; may be appropriate after complex stenting. ^[2]
• After drug-eluting stent for chronic coronary disease: delay elective surgery for at least 6 months. ^[2]
• Time-sensitive surgery: may be considered 3 months after stenting if delaying surgery outweighs the thrombosis risk; the ESC guideline allows non-cardiac surgery as early as 1 month after stenting for chronic coronary disease with dual antiplatelet therapy. ^[2]
• Elective surgery requiring interruption of at least one antiplatelet agent is harmful within 30 days of stent placement. ^[2]

The Brazilian 2024 guideline attributes the following intervals for surgery after percutaneous coronary intervention: 6 months or more (Class I), 3 to 6 months (Class IIa), 30 days to 3 months (Class IIb), under 30 days (Class III) for elective indications; and 12 months or more (Class I) after an acute coronary syndrome. ^[4]

For most patients on therapeutic anticoagulation, withholding direct oral anticoagulants or warfarin before surgery is appropriate, and bridging with parenteral heparin is not indicated in most patients because of increased bleeding risk. ^[2] In high thrombotic risk situations, such as a mechanical mitral valve, left ventricular thrombus within the past 3 months, or atrial fibrillation with recent stroke, bridging with heparin or low-molecular-weight heparin can be used. ^[2] Direct oral anticoagulants do not require bridging because of their shorter half-lives. ^{[2] [3]}

Warfarin is usually stopped 4 to 5 (or more) days before a higher-risk procedure, with bridging considered high-thrombosis-risk patients. Direct oral anticoagulants are stopped according to their half-life and renal function, usually 1 to 4 days before surgery, a point on which local formularies should be followed.

Unstable angina, acute myocardial infarction, decompensated heart failure, significant arrhythmia or severe symptomatic valve disease must be identified and treated before an elective operation; in that case surgery is postponed for days to weeks. ^{[2] [3]} Uncontrolled systemic hypertension above 180 by 110 mmHg is listed among unstable cardiovascular conditions in the Brazilian 2024 guideline; either guideline suggests optimising blood pressure first and delaying elective surgery when it is very high. ^{[2] [4]}

Heart failure carries substantial perioperative risk. Patients should be euvolaemic and on guideline-directed therapy before surgery, with titration of ACE inhibitor or ARB, beta-blocker, mineralocorticoid receptor antagonist and SGLT2 inhibitor where ejection fraction is reduced. ^[4] Echocardiography is required if there are signs or symptoms of heart failure, to assess ventricular function and valves. ^[2]

Valvular disease may be silent even when severe, and the risk of non-cardiac surgery rises particularly with obstructive lesions such as aortic stenosis and mitral stenosis, where volume shifts or arrhythmia can precipitate decompensation. ^[2] Echocardiography is indicated for known or suspected moderate-to-severe valvular disease; a study confirmed within 12 months in a stable, asymptomatic patient does not need to be repeated. ^[2]

Severe symptomatic disease should be treated before elective non-cardiac surgery, according to standard pathways, including transcatheter or surgical valve intervention; patients with prosthetic valves should have an anticoagulation plan. ^[2]

A recent infarction or recent stent changes the arithmetic but is not itself a reason to delay surgery indefinitely. Acute situations need cardiology management first, and stable coronary artery disease is treated medically unless it meets standard revascularisation indications. ^[3] Antiplatelet timing and stent type should be decided jointly with the cardiology team. ^[2]

Postoperative surveillance is matched to risk. High-risk patients benefit from continuous telemetry, repeated haemodynamic checks and troponin monitoring in the first 48 to 72 hours. ^{[2] [3]}

Myocardial injury after non-cardiac surgery (MINS) is diagnosed when troponin exceeds the 99th percentile with a rise and fall pattern within 48 to 72 hours postoperatively, often without chest pain. ^[3] Daily troponin testing for 48 to 72 hours is considered in high-risk patients. ^[3]

Tachycardia and hypotension should be treated promptly: even brief intraoperative or early postoperative hypotension is associated with myocardial injury and kidney injury. ^[3] The usual target is a mean arterial pressure of at least 60 to 65 mmHg or a systolic pressure of at least 90 mmHg. ^[2]

New atrial fibrillation is treated with rate control: a beta-blocker or a non-dihydropyridine calcium channel blocker is the usual first step, with anticoagulation added if the rhythm persists beyond 48 hours and bleeding risk permits. ^[3]

Evidence of myocardial injury should trigger cardioprotective therapy and risk-factor revision: a beta-blocker (especially if tachycardic or hypertensive), aspirin, a statin, an ACE inhibitor where appropriate, and consideration of anticoagulation, for example dabigatran 110 mg twice daily as studied in MANAGE, once surgical haemostasis is secure. ^[3] A perioperative cardiac event predicts future events, so secondary prevention and cardiac rehabilitation should continue after discharge. ^[3]

Perioperative complications include:

• Myocardial infarction and myocardial injury after non-cardiac surgery, most often silent. ^[3]
• Arrhythmias, in particular new-onset atrial fibrillation, which is more common after thoracic or major abdominal procedures. ^[3]
• Acute heart failure from volume overload or myocardial ischaemia. ^[3]
• Hypotension and hypertension with end-organ injury. ^[3]
• Thromboembolism, including stent thrombosis if antiplatelet therapy is interrupted, and stroke. ^[2]
• Cardiac arrest, uncommon but with high mortality. ^[3]

Stress testing, echocardiography and biomarkers each identify risk but cannot prevent these events; prevention rests on selection, optimisation and monitoring.

The same principles apply wherever surgery is done, and a careful history and examination with calculation of the RCRI do most of the work. An honest assessment of how many stairs the patient can climb, a resting ECG where available, and a transthoracic echocardiogram if available answer most clinical questions; expensive coronary imaging is rarely what determines safety. Continue beta-blockers and statins, manage blood pressure, correct anaemia with iron, and continue aspirin where it is indicated. Clear documentation that assessment and management followed guideline criteria also protects clinicians from medicolegal dispute. ^{[1] [2]}

• Perioperative cardiac assessment is a structured approach rather than a list of preoperative tests: history, examination, score, measure fitness, plan.
• The reference guideline editions are the 2024 AHA/ACC and 2022 ESC documents; they agree that testing should be ordered only when a result changes management. ^{[2] [4]}
• The RCRI combines six common clinical factors; 0 is low risk, 1 is low-to-intermediate, and 2 or more indicate elevated risk. ^{[1] [3]}
• Functional capacity matters as much as any score: under 4 METs is poor capacity, and a Duke Activity Status Index under 34 flags higher 30-day death or infarction risk. ^{[1] [2] [3]}
• Echocardiography is indicated for new or worsening heart failure, a new murmur, suspected valve disease or poor functional capacity before higher-risk surgery; it is not routine in asymptomatic patients. ^{[1] [2]}
• Stress testing and coronary CT are considered only when functional capacity is poor or unknown and surgical risk is elevated; patients with capacity of 4 METs or more do not need them. ^{[1] [2]}
• Natriuretic peptides and troponin refine risk and have good negative predictive value; they need not be measured in low-risk patients. ^{[1] [3]}
• Active cardiac conditions, serious valve disease, uncontrolled hypertension and a recent acute infarction are reasons to stabilise and delay elective surgery. ^{[2] [3] [4]}
• Continue beta-blockers and statins, avoid starting beta-blockers within 7 days of surgery, and time any initiation weeks ahead at low dose. ^{[2] [3]}
• Hold ACE inhibitors and ARBs on the morning of surgery when hypotension is a concern; calcium channel blockers and diuretics are usually continued, and aspirin for secondary prevention is usually continued. ^{[2] [3] [4]}
• Myocardial injury after non-cardiac surgery is detected by troponin in the 48 to 72 hours after surgery; high-risk patients need surveillance and secondary prevention. ^[3]

Perioperative care and preoperative assessment, acute coronary syndromes, heart failure, valvular heart disease, coronary artery disease and chronic coronary syndrome, arrhythmias, atrial fibrillation, hypertension, diabetes mellitus, anaemia, chronic kidney disease, peripheral artery disease, stroke, bleeding and anticoagulation, postoperative complications, functional capacity and exercise testing, echocardiography, stress testing and cardiac imaging, surgical risk and enhanced recovery.

Written for a worldwide readership: drug names are given as generics. Local guidelines, formularies and practice protocols should always take precedence. Last verified 2026-10-31.