Steps: Major Clinical Predictors

Clarifications

Unstable coronary syndromes:

• Acute (≤ 7 days) or Recent (> 7 but ≤ 30 days) MI with evidence of important ischemia by clinical symptoms or noninvasive study.
• Unstable or severe angina (class III, IV). May include stable angina in patients who are extremely sedentary.

Significant arrhythmias:

• High-grade AV block
• Symptomatic ventricular arrythmias with underlying heart disease
• Supraventricular arrythmia with uncontrolled ventricular rate
  

• Major Clinical Predictors: Does the patient have an unstable coronary syndrome or a major clinical predictor of risk? When elective noncardiac surgery is being considered, the presence of unstable coronary disease, decompensated HF, symptomatic arrhythmias, and/or severe valvular heart disease usually leads to cancellation or delay of surgery until the problem has been identified and treated.

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Steps: Intermediate Clinical Predictors

Clarifications

• Intermediate Clinical Predictors: Does the patient have intermediate clinical predictors of risk? The presence or absence of prior MI by history or ECG, angina pectoris, compensated or prior HF, preoperative creatinine greater than or equal to 2 mg per deciliter, and/or diabetes mellitus helps to further stratify clinical risk for perioperative coronary events. Consideration of functional capacity and level of surgery-specific risk allows a rational approach to identify patients most likely to benefit from further noninvasive testing.
• Testing: Patients without major but with intermediate predictors of clinical risk and moderate or excellent functional capacity can generally undergo intermediate-risk surgery with little likelihood of perioperative death or MI. Conversely, further noninvasive testing is often considered for patients with poor functional capacity or moderate functional capacity but higher-risk surgery, especially for patients with 2 or more intermediate predictors of risk.

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Steps: Minor Clinical Predictors

Clarifications

Abnormal ECG:

• LVH, LBBB, ST-T abnormalities

Rythm other than sinus:

• e.g.,atrial fibrillation

Low functional capacity:

• e.g., "inability to climb 1 flight of stairs with a grocery bag"

• "Minor" Clinical Predictors: Noncardiac surgery is generally safe for patients with neither major nor intermediate predictors of clinical risk and moderate or excellent functional capacity (4 METs or greater). Additional testing may be considered on an individual basis for patients without clinical markers but with poor functional capacity who are facing higher-risk operations, particularly those with several minor clinical predictors of risk who are scheduled to undergo vascular surgery.
• Testing: The results of noninvasive testing can be used to determine the need for additional preoperative testing and treatment. In some patients with documented CAD, the risk of coronary intervention or corrective cardiac surgery may approach or even exceed the risk of the proposed noncardiac surgery. This approach may be appropriate, however, if it significantly improves the patient’s long-term prognosis.

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