Educational draft · awaiting clinical reviewThe full textbook explains uncertainty but does not replace live national or local guidance, specialist advice, or current prescribing information.
Estimate cardiovascular risk before non-cardiac surgery, identify conditions that need treatment or delay, and plan proportionate investigation, medicines and postoperative surveillance.
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.
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.
Assessment quantifies and modifies risk; it cannot certify that an operation is risk-free.
A plausible abnormal result is not enough: decide beforehand how each possible result would alter care.
Musculoskeletal limitation may obscure cardiac reserve; conversely, good reported activity does not override active cardiac symptoms.
Stable coronary disease is not revascularised merely to pass a preoperative assessment.
Analgesia and reduced activity can mask postoperative ischaemia, so selected high-risk patients may benefit from biomarker surveillance.
Premature antiplatelet interruption can cause catastrophic stent thrombosis; timing and bleeding decisions need interventional-cardiology input.
Delaying emergency surgery for a cardiac test that cannot change immediate management.
Ordering an echocardiogram or stress test routinely without a management-changing clinical question.
Using a single risk score as a substitute for symptoms, frailty, surgical stress and shared decision-making.
Stopping antiplatelet or anticoagulant treatment without documenting thrombotic risk, timing and restart ownership.
Calling a postoperative troponin rise a type 1 myocardial infarction without evaluating competing mechanisms.
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A 76-year-old awaiting elective major abdominal surgery has a systolic murmur and new exertional syncope. What is the best next step?
National guidance is shown before implementation-dependent detail. Apply principles in context and verify current guidance when a decision affects care. Source check completed 27 Aug 2026; clinical approval remains outstanding.
Editorial contact: Doctor’s Passport editorial team. Source-check date is separate from clinical approval. Report a content problem · Content changes