How is cardiac risk stratified before surgery

Guidelines for cardiac risk stratification developed by the American College of Cardiology and American Heart Association include assessment of: A. CLINICAL RISK FACTORS

• Major: Unstable coronary syndromes, decompensated congestive heart failure (CHF), significant arrhythmia, severe valvular disease

• Intermediate: Mild angina pectoris, prior myocardial infarction, compensated CHF, diabetes mellitus, renal insufficiency

• Minor: Advanced age, abnormal ECG, rhythm other than sinus, low functional capacity, history of stroke, uncontrolled hypertension


• High risk: Major emergency surgery, vascular surgery, any procedure that is prolonged with large fluid shifts, blood loss, or both

• Intermediate risk: General orthopedic procedures, carotid endarterectomies, peritoneal and thoracic procedures

• Low risk: Endoscopic procedure, superficial procedure, cataract surgery, breast surgery


Application of an algorithm based on these guidelines leads to a decision to proceed with surgery, to cancel surgery pending coronary artery intervention, or to delay surgery for additional noninvasive cardiac testing. The most recent guidelines (2007) determine the need for additional cardiac evaluation prior to elective surgery based on a Revised Cardiac Risk Index and the patient's functional status quantified in metabolic equivalents (METS).

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