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Preoperative Cardiac Risk Assessment (ESC 2022)

Preoperative Cardiac Risk Assessment (ESC 2022): Adult: non-cardiac surgery planned → Emergency or urgent surgery? → Urgent surgery: do not delay it for...

Pathway Overview

22 steps

Algorithm Steps

22 total

  1. 01Start

    Adult: non-cardiac surgery planned

    Pre-operative cardiovascular risk check (ESC 2022). Adults only.

  2. 02Decision

    Emergency or urgent surgery?

    Surgery must go ahead without delay to save life, limb or organ.

  3. If Yes
    1. Emergency or urgent
    2. 03Action

      Urgent surgery: do not delay it for cardiac tests

      Emergency or urgent: the team decides which cardiac tests are feasible.

      • Chest pain or suspected new heart disease: multidisciplinary plan with the lowest total risk
      • AF with acute or worsening haemodynamic instability: emergency electrical cardioversion
      • Taking a NOAC: stop it now. Anticoagulant and bleeding-risk surgery: reverse per local protocol (dabigatran: consider idarucizumab; warfarin: vitamin K and prothrombin complex concentrate)
      • SGLT2 inhibitor not stopped 3 days before: check blood ketones and base excess before surgery; monitor ketones after surgery
      • After surgery: close follow-up and treatment of any heart disease
    3. 04Warning

      Medicines: check antiplatelets, anticoagulants, SGLT2 inhibitors

      Give written instructions for each medicine.

      • Coronary stent or ACS: do not stop antiplatelets without cardiology advice. Delay elective surgery 6 months after elective PCI, 12 months after ACS
      • SGLT2 inhibitor: omit for at least 3 days (2 days before and the day of surgery); ketoacidosis risk
      • NOAC or warfarin: plan by drug, kidney function and bleeding risk. Minor bleeding-risk surgery: no interruption (NOAC: at trough, 12-24 h after last dose). Mechanical heart valve: plan bridging with cardiology
    4. 05Action

      Other medicines around surgery

      Continue or adjust as below.

      • Continue beta-blockers and statins. Do not start a beta-blocker routinely (Class III)
      • No heart failure: consider withholding ACE inhibitor or ARB on the day of surgery
      • Previous PCI: continue aspirin if bleeding risk allows. Intracranial, spinal or vitreoretinal surgery: stop aspirin at least 7 days before (recent stent: cardiology first)
      • Time-sensitive surgery after elective PCI: give at least 1 month of DAPT first. After STEMI or high-risk NSTE-ACS: consider at least 3 months
      • If a P2Y12 inhibitor must stop: ticagrelor 3-5 days, clopidogrel 5 days, prasugrel 7 days before surgery
      • Anticoagulant: no bridging if thrombotic risk is low or moderate. Mechanical mitral or tricuspid valve, older mechanical aortic valve, or mechanical aortic valve with a risk factor: consider LMWH or UFH bridging
      • Restart antiplatelets as soon as possible after surgery (within 48 h)
      • Pacemaker or ICD: device check and peri-operative plan. ICD switched off: continuous ECG and defibrillator ready
    5. 06Action

      After surgery: check for myocardial injury

      Age 65+, risk factors or CVD, after intermediate- or high-risk surgery.

      • hs-cTn at 24 h and 48 h after surgery
      • Rise from the pre-op level of more than the upper reference limit on day 1 or 2: myocardial injury (PMI)
      • PMI: clinical review, ECG and echo to find the cause
    6. 07Outcome

      Proceed to surgery with a documented risk plan

      Share the risk estimate and plan with the patient and team.

    If No
    1. Not urgent
    2. 08Decision

      Time-sensitive surgery (for example cancer)?

      Not urgent, but delay risks loss of limb or organ function or more complications.

    3. If Yes
      1. Time-sensitive
      2. 09Action

        Time-sensitive surgery: team decides on tests

        Time-sensitive: multidisciplinary decision on individual cardiac tests. If time allows, assess as for elective surgery (next steps).

      3. 10Decision

        Symptoms or unstable heart disease?

        Chest pain, new dyspnoea or oedema, new murmur with symptoms, ACS in the last 12 months, symptomatic severe valve disease, or uncontrolled arrhythmia.

      4. If Yes
        1. Symptoms or unstable
        2. 11Warning

          Symptoms or unstable heart disease: delay elective surgery

          Assess and treat first, with cardiology. Uncontrolled arrhythmia: treat before elective surgery.

          • Chest pain or suspected CAD: diagnostic work-up before surgery. ACS: treat as ACS; delay elective surgery 12 months
          • Dyspnoea or oedema: ECG and NT-proBNP/BNP; TTE if raised. New murmur with symptoms or signs: TTE
          • Symptomatic severe aortic stenosis: AVR (SAVR or TAVI) before elective intermediate- or high-risk surgery
        3. 12Action

          Elective surgery: history, examination, blood tests

          All elective patients (Class I).

          • History and examination: CV risk factors, known CVD, other disease
          • Haemoglobin and renal function before intermediate- or high-risk surgery; treat anaemia first
          • Stop smoking more than 4 weeks before surgery; optimise treatment of CVD and risk factors
          • Age 70 or more and intermediate- or high-risk surgery: consider frailty screening
          • Family history of genetic cardiomyopathy: ECG and TTE at any age
        4. 13Action

          Optional: estimate risk with RCRI

          1 point each. 30-day death, MI or cardiac arrest: 0 = 4%, 1 = 6%, 2 = 10%, 3 or more = 15%. The tests below depend on surgical risk and patient group, not on RCRI alone.

          • Ischaemic heart disease
          • Heart failure
          • Stroke or TIA
          • Diabetes treated with insulin
          • Creatinine more than 177 µmol/L (2.0 mg/dL)
          • High-risk surgery: intraperitoneal, intrathoracic or suprainguinal vascular
        5. 14Decision

          Low-risk surgery?

          Low risk (under 1% 30-day CV death, MI or stroke): breast, dental, thyroid, eye, superficial, reconstructive, minor gynaecological, minor orthopaedic (meniscectomy), minor urological (TURP), VATS minor lung resection. Hip and spine surgery are not low risk.

        6. If Yes
          1. Low-risk surgery
          2. 15Action

            Low-risk surgery: no routine cardiac tests

            Low-risk surgery: routine ECG, troponin, BNP, echo and stress tests are not recommended. Known CVD: manage that disease (ESC 2022 section 6).

          3. Path rejoins step 04Shared downstream outcome
          If No
          1. Intermediate or high risk
          2. 16Decision

            Age 65 or more, CV risk factors or known CVD?

            Intermediate- or high-risk surgery. Risk factors: hypertension, smoking, dyslipidaemia, diabetes, family history of CVD.

          3. If Yes
            1. 65+, risk factors or CVD
            2. 17Action

              Age 65+, risk factors or CVD: ECG and biomarkers

              Before intermediate- or high-risk surgery (Class I).

              • 12-lead ECG
              • hs-cTn T or I before surgery, and at 24 h and 48 h after
              • BNP or NT-proBNP (Class IIa)
              • Abnormal result: ask a cardiologist
            3. 18Action

              Age 65+, risk factors or CVD: functional capacity

              Ask: can the patient climb 2 flights of stairs? (Class IIa)

              • Cannot, or unable to tell: poor functional capacity
              • DASI can be used: score under 34 = higher risk
              • Known CVD and high-risk surgery: cardiology consultation and multidisciplinary decision
            4. 19Decision

              Cannot climb 2 flights of stairs?

              Poor or unknown functional capacity.

            5. If Yes
              1. Poor or unknown
              2. 20Action

                Poor capacity: further cardiac tests

                Poor functional capacity: choose tests by surgical risk.

                • High-risk surgery with high likelihood of CAD or high clinical risk: stress imaging (Class I)
                • Before high-risk surgery with poor capacity, high NT-proBNP/BNP or a murmur: TTE
                • Coronary angiography and revascularisation: same indications as without surgery
                • Discuss risks and benefits with the patient
              3. Path rejoins step 04Shared downstream outcome
              If No
              1. Climbs 2 flights
              2. 21Action

                Can climb 2 flights: no further tests

                Good functional capacity: proceed. Routine echo or stress imaging is not recommended. Before high-risk surgery, raised NT-proBNP/BNP or a murmur: TTE (Class I).

              3. Path rejoins step 04Shared downstream outcome
            If No
            1. Under 65, no risk factors
            2. 22Action

              Age under 65, no CVD or risk factors

              Intermediate-risk surgery: no routine cardiac tests. High-risk surgery and age over 45: consider ECG and biomarkers (Class IIa).

            3. Path rejoins step 04Shared downstream outcome
        If No
        1. Stable
        2. Path rejoins step 12Shared downstream outcome
      If No
      1. Elective
      2. Path rejoins step 10Shared downstream outcome

Guideline Source

2022 ESC Guidelines on cardiovascular assessment and management of patients undergoing non-cardiac surgery

DOI: 10.1093/eurheartj/ehac270View Guideline

Clinical Safety Information

Clinical Decision Support — Not a Substitute for Clinical Judgment

Individual patient factors may require deviation from these recommendations.

Known Limitations

  • Adults only. Does not replace cardiology or anaesthetic review for complex, unstable or high-risk patients.
  • Covers cardiovascular risk only; anaesthetic, airway, aspiration (including GLP-1 RA) and full diabetes plans follow local guidance.
  • Antithrombotic timing is summarised; bleeding-risk and bridging decisions need the full ESC 2022 section 5.3 and local protocol.

Contraindicated Populations

pediatric

Applicable Regions

EUUSAUNZ

AU: No separate national cardiac pre-op guideline; ESC 2022 used. SGLT2 inhibitor timing per ADS-ADEA-ANZCA-NZSSD alert (May 2023). Creatinine in µmol/L.

EU: ESC 2022 non-cardiac surgery guideline (endorsed by ESAIC).

NZ: SGLT2 inhibitor timing per ADS-ADEA-ANZCA-NZSSD alert (May 2023).

US: 2024 ACC/AHA perioperative guideline is the local standard; broadly similar approach.

Version 2Next review: 2027-09-30

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Frequently Asked Questions

What is the Preoperative Cardiac Risk Assessment (ESC 2022)?

The Preoperative Cardiac Risk Assessment (ESC 2022) is a risk assessment clinical algorithm for Cardiology. It provides a structured decision tree to guide clinical decision-making, based on 2022 ESC Guidelines on cardiovascular assessment and management of patients undergoing non-cardiac surgery.

What guideline is the Preoperative Cardiac Risk Assessment (ESC 2022) based on?

This algorithm is based on 2022 ESC Guidelines on cardiovascular assessment and management of patients undergoing non-cardiac surgery (DOI: 10.1093/eurheartj/ehac270).

What are the limitations of the Preoperative Cardiac Risk Assessment (ESC 2022)?

Known limitations include: Adults only. Does not replace cardiology or anaesthetic review for complex, unstable or high-risk patients.; Covers cardiovascular risk only; anaesthetic, airway, aspiration (including GLP-1 RA) and full diabetes plans follow local guidance.; Antithrombotic timing is summarised; bleeding-risk and bridging decisions need the full ESC 2022 section 5.3 and local protocol.. Individual patient factors may require deviation from these recommendations.

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