01Purpose and principlesWhat the assessment is for and the core concepts behind it.
Perioperative assessment is a stepwise decision process, not blanket cardiac clearance. Define urgency and surgical stress, identify unstable disease, assess clinical risk and functional capacity, then choose only investigations that can alter management.
The endpoint is a shared plan: proceed, optimise first, alter the surgical or anaesthetic strategy, intensify postoperative surveillance, or defer. Decisions should involve the surgeon, anaesthetist and relevant cardiovascular specialist when risk is material or uncertain.
NICE NG45 specifies which routine tests to offer or consider by ASA grade, surgical magnitude and comorbidity; NICE NG180 embeds these decisions within individualised perioperative care.
Key points
- Start with surgical urgency: emergency treatment must not be delayed by tests that cannot change immediate management.
- Estimate both procedure-related risk and patient-related risk; previous cardiovascular disease, symptoms, frailty, renal disease and diabetes materially alter risk.
- New chest pain, decompensated heart failure, unstable arrhythmia or severe symptomatic valve disease requires assessment before elective surgery proceeds.
- Functional capacity is clinically useful: inability to climb two flights of stairs or perform moderate activity suggests reduced reserve but is not a diagnosis.
- Order a preoperative test only when the result could change the operation, anaesthetic plan, treatment or postoperative monitoring.
- Do not request routine resting echocardiography; use it for unexplained dyspnoea, heart-failure features or a murmur with cardiac symptoms when the result will affect care.
- Document a procedure-specific plan for anticoagulants, antiplatelets, implanted cardiac devices and chronic cardiovascular medicines.
- For selected higher-risk patients, perioperative troponin surveillance can detect otherwise silent myocardial injury and should trigger clinical assessment rather than an isolated laboratory label.
02Indications, selection and cautionsWhen it is useful, when urgency changes and important limitations.
New or crescendo exertional chest pressure, rest pain, dynamic ECG change or a recent acute coronary syndrome needs urgent evaluation rather than elective anaesthesia.
Orthopnoea, pulmonary oedema, raised JVP, new hypoxia or rapidly increasing oedema indicates high perioperative risk and requires stabilisation.
Syncope, haemodynamic compromise, uncontrolled rapid ventricular rate, high-grade AV block or symptomatic ventricular arrhythmia requires prompt treatment.
Exertional syncope, angina or dyspnoea with an ejection murmur raises concern for severe aortic stenosis; severe mitral disease or pulmonary hypertension can also substantially increase risk.
Low functional capacity, frailty, previous heart failure, stroke, coronary disease, renal impairment or insulin-treated diabetes increases risk even without current symptoms.
Recent coronary stenting, mechanical valve anticoagulation, recent venous thromboembolism, pacemaker dependence or an ICD requires an explicit perioperative plan.
03Method and interpretationA systematic approach to the test and its findings.
Read from the initial assessment onwards. Tests may run in parallel in urgent care; first-line, preferred, confirmatory, definitive and gold-standard labels appear only when the chapter explicitly states them.
- 01
Resting 12-lead ECGFirst step - Why
- Establish rhythm and identify conduction disease, previous infarction or ischaemic change when indicated by age, ASA grade, comorbidity and surgical magnitude.
- Interpretation and limitations
- Compare with a previous tracing; a new abnormality should be interpreted clinically and does not automatically mandate cancellation or stress testing.
- 02
Full blood count, renal function and electrolytes - Why
- Identify anaemia, renal impairment and electrolyte disturbance when NICE NG45 indicates testing or comorbidity makes the result actionable.
- Interpretation and limitations
- Correct important abnormalities and use renal function to plan contrast, fluids and interruption or resumption of renally cleared medicines.
- 03
Transthoracic echocardiography - Why
- Assess suspected heart failure, unexplained dyspnoea or a murmur accompanied by cardiac symptoms when the result will change care.
- Interpretation and limitations
- Define ventricular function, valve severity and pulmonary pressure; do not use a normal ejection fraction to exclude all perioperative cardiac risk.
- 04
Stress imaging or anatomical coronary assessment - Why
- Clarify inducible ischaemia or coronary anatomy in a selected higher-risk patient with poor functional capacity when the answer could change management.
- Interpretation and limitations
- Do not screen routinely or revascularise stable coronary disease solely to make surgery possible; apply the same prognostic indications used outside surgery.
- 05
Natriuretic peptide and cardiac troponin - Why
- Refine risk and provide a baseline or postoperative surveillance marker in selected patients undergoing intermediate- or high-risk surgery.
- Interpretation and limitations
- An abnormal result warrants clinical evaluation and comparison over time; postoperative myocardial injury may be clinically silent and has several possible mechanisms.
- 06
Device interrogation - Why
- Define pacemaker dependence, battery status, programmed mode and ICD therapy before surgery with electromagnetic interference risk.
- Interpretation and limitations
- Agree magnet or reprogramming strategy and postoperative restoration/check with the cardiac device service.
04Clinical next stepsHow the result changes management or prompts escalation.
01FirstTriage urgency and active diseaseFirst stepAny patient being considered for non-cardiac surgery.+
- 1Classify the procedure as emergency, urgent, time-sensitive or elective and estimate its physiological and bleeding burden.
- 2Ask specifically about chest pain, dyspnoea, orthopnoea, syncope, palpitations, recent vascular events and change in exercise tolerance; examine cardiovascular status.
- 3If an unstable cardiac condition is suspected, arrange urgent assessment and defer elective surgery while the surgical and anaesthetic teams reconsider timing.
- 4If emergency surgery must proceed, stabilise what can be stabilised without harmful delay and plan enhanced intra- and postoperative care.
02NextEstimate risk and choose testsNo active cardiac emergency and surgery is planned.+
- 1Combine surgical risk with comorbidity, frailty and a validated clinical risk estimate; establish functional capacity from usual activity or structured assessment.
- 2Use the NICE NG45 matrix to select routine blood tests and ECG by ASA grade, surgical size and comorbidity.
- 3Request echocardiography, biomarkers or ischaemia testing only for a defined clinical question whose answer could alter care.
- 4Discuss materially elevated or uncertain risk in a multidisciplinary setting and record the shared decision.
03EscalationOptimise and make a perioperative planEscalationEstablished cardiovascular disease, recent PCI, significant test abnormality or elevated predicted risk.+
- 1Treat cardiovascular disease according to its usual prognostic indication; do not perform prophylactic coronary revascularisation solely to reduce operative risk.
- 2Agree continuation, interruption and restart of anticoagulants and antiplatelets, balancing thrombosis, stent and bleeding risks with the relevant specialists.
- 3Plan device management, anaesthetic technique, haemodynamic goals, monitored bed level and postoperative ECG/troponin surveillance where appropriate.
- 4Proceed, modify or defer only after the patient understands the surgical and cardiovascular alternatives and residual risk.
04PostoperativeRespond to myocardial injury or instabilityChest pain, dyspnoea, arrhythmia, haemodynamic deterioration or an abnormal surveillance troponin after surgery.+
- 1Assess ABCDE, obtain a 12-lead ECG and repeat troponin while treating hypoxia, hypotension, anaemia, sepsis or uncontrolled tachycardia.
- 2Differentiate plaque rupture, supply-demand imbalance, pulmonary embolism, heart failure and non-cardiac causes rather than assuming one mechanism.
- 3EscalationEscalate promptly to anaesthesia/critical care and cardiology when instability, dynamic ECG change or significant biomarker rise is present.
- 4Document the event, secondary-prevention needs and follow-up before discharge.
05Risks, monitoring and follow-upComplications, safety checks and further assessment.
- Record baseline symptoms, functional capacity, blood pressure, pulse, volume status and oxygen saturation.
- Reassess if surgery is delayed or symptoms change; a historic normal echocardiogram is not reassurance against new disease.
- Confirm in writing the last and next doses of every antiplatelet and anticoagulant and who owns the restart decision.
- Use continuous ECG and appropriate invasive haemodynamic monitoring when the procedure and patient risk justify it.
- Measure postoperative ECG/troponin in selected high-risk patients and investigate a dynamic rise or clinical deterioration.
- After surgery, monitor fluid balance, renal function, haemoglobin, electrolytes and timely resumption of chronic cardiovascular treatment.
06Special situationsVariants, exceptions and circumstances that change the usual approach.
Clearance is the wrong concept
Assessment quantifies and modifies risk; it cannot certify that an operation is risk-free.
Testing needs a decision consequence
A plausible abnormal result is not enough: decide beforehand how each possible result would alter care.
Functional capacity is contextual
Musculoskeletal limitation may obscure cardiac reserve; conversely, good reported activity does not override active cardiac symptoms.
Revascularisation keeps its usual indications
Stable coronary disease is not revascularised merely to pass a preoperative assessment.
Silent injury matters
Analgesia and reduced activity can mask postoperative ischaemia, so selected high-risk patients may benefit from biomarker surveillance.
Recent stents change the conversation
Premature antiplatelet interruption can cause catastrophic stent thrombosis; timing and bleeding decisions need interventional-cardiology input.
07Common pitfallsFrequent interpretation and management errors.
- 01
Delaying emergency surgery for a cardiac test that cannot change immediate management.
- 02
Ordering an echocardiogram or stress test routinely without a management-changing clinical question.
- 03
Using a single risk score as a substitute for symptoms, frailty, surgical stress and shared decision-making.
- 04
Stopping antiplatelet or anticoagulant treatment without documenting thrombotic risk, timing and restart ownership.
- 05
Calling a postoperative troponin rise a type 1 myocardial infarction without evaluating competing mechanisms.