[Durgical](https://durgical.com/en/) › [DurgiPedia](https://durgical.com/en/durgipedia/) › [Anaesthesia and ICU](https://durgical.com/en/anaesthesia/) › [Preoperative assessment](https://durgical.com/en/anaesthesia/areas/preop/) › Cardiac risk before non-cardiac surgery

# Cardiac risk before non-cardiac surgery

- Assessment

Before an operation the doctor estimates how likely the heart is to suffer, and decides whether surgery can go ahead or needs more tests first.

Updated Nov 13, 2026

## Key points

- Active cardiac conditions (acute coronary syndrome, decompensated heart failure, significant arrhythmia, severe valve disease) delay elective surgery.
- Revised cardiac risk index: high-risk surgery, ischaemic heart disease, heart failure, cerebrovascular disease, insulin-treated diabetes, raised creatinine.
- Good functional capacity (at least four metabolic equivalents, about two flights of stairs) usually means no further cardiac testing.
- Order stress testing or other investigations only if the result would change management; coronary revascularisation just to get through surgery rarely helps.
- Continue long-term beta-blockers and statins; do not start a beta-blocker on the day of surgery.

## What it is

Major cardiac complications after non-cardiac surgery (myocardial infarction or injury, heart failure, serious arrhythmia and cardiac death) are a leading cause of perioperative death. Assessment follows a stepwise logic. First, is the surgery an emergency? If so, proceed and manage risk during and after surgery. Second, is there an active cardiac condition (acute coronary syndrome, decompensated heart failure, a significant arrhythmia or severe symptomatic valve disease)? If so, elective surgery waits until it is treated. Third, estimate risk by combining the patient's risk factors with the risk of the operation, for example with the revised cardiac risk index. Low-risk patients proceed. For elevated risk, functional capacity decides: a patient who can do at least four metabolic equivalents (climb two flights of stairs) without symptoms usually proceeds without further testing. Further tests are ordered only if their result would change management. Blood pressure is part of the picture: elective surgery is usually postponed when it is very high (around 180/110 mmHg or more), and long-term cardiac medicines are generally continued.

## What to assess

- Urgency of the operation: emergency, urgent, time-sensitive or elective.
- Active cardiac conditions that make elective surgery unsafe.
- Patient risk factors: ischaemic heart disease, heart failure, stroke or transient ischaemic attack, insulin-treated diabetes, kidney dysfunction.
- Surgical risk: high for intraperitoneal, intrathoracic and suprainguinal vascular surgery; low for superficial, eye, breast and many endoscopic procedures.
- Functional capacity in metabolic equivalents, from the history.
- Blood pressure control and current cardiac medicines, including antiplatelets after coronary stents.

## How it is done (and why)

- Establish the urgency of the operation — an emergency goes ahead; work-up must not delay life-saving surgery.
- Look for active cardiac conditions — these carry such high risk that elective surgery waits until they are treated.
- Count the patient's risk factors and the surgical risk — the revised cardiac risk index combines both into an estimate.
- If risk is low, proceed — further tests in low-risk patients mostly find false positives and delay care.
- If risk is elevated, ask about functional capacity — at least four metabolic equivalents without symptoms predicts a good outcome.
- With poor or unknown capacity, consider further tests only if they would change management — testing alone does not lower risk.
- Obtain an ECG and other tests for those with known disease or symptoms — a baseline helps interpret postoperative changes.
- Check blood pressure and cardiac medicines — very high pressure postpones elective surgery; long-term drugs usually continue.
- Plan monitoring and postoperative care to match the risk — most cardiac events happen in the first days after surgery.

## Revised cardiac risk index: one point for each factor; more points, higher risk

| Factor | What counts |
| --- | --- |
| High-risk surgery | Intraperitoneal, intrathoracic or suprainguinal vascular surgery |
| Ischaemic heart disease | Previous myocardial infarction, angina, positive stress test, nitrate use or pathological Q waves |
| Heart failure | History of heart failure, pulmonary oedema or a third heart sound |
| Cerebrovascular disease | Previous stroke or transient ischaemic attack |
| Diabetes treated with insulin | Insulin before surgery |
| Kidney dysfunction | Preoperative creatinine above about 177 µmol/L |

## Findings that change the plan

- Myocardial infarction within about 60 days: delay elective non-cardiac surgery when possible.
- Recent coronary stent: elective surgery is usually delayed while dual antiplatelet therapy is needed; decisions involve the cardiologist.
- Severe aortic stenosis with symptoms: assess and treat the valve before elective surgery.
- Blood pressure around 180/110 mmHg or more: postpone elective surgery and control it; below that, proceed and continue treatment.
- New breathlessness, chest pain or a new murmur at the visit: investigate before elective surgery.

## Next step

- Postpone elective surgery and refer to cardiology for any active cardiac condition.
- Discuss with a senior anaesthetist and the cardiologist any patient with a recent stent, recent infarction or severe valve disease before stopping antiplatelets.
- Continue long-term beta-blockers, statins and most antihypertensives, following local guidance on the day of surgery.
- Plan postoperative monitoring for elevated-risk patients, and look actively for myocardial injury, which is often silent.
- Ask the primary care doctor to review blood pressure and cardiac treatment after surgery.

## Test yourself

Think of the answer, then tap the question to see it.

## Which active cardiac conditions require elective non-cardiac surgery to be postponed?

Acute coronary syndrome, decompensated heart failure, a significant arrhythmia and severe symptomatic valve disease, such as severe aortic stenosis.

## Which six factors make up the revised cardiac risk index?

High-risk surgery, ischaemic heart disease, heart failure, cerebrovascular disease, insulin-treated diabetes and a raised preoperative creatinine.

## When does an elevated-risk patient usually need no further cardiac testing before surgery?

When functional capacity is good, at least four metabolic equivalents (climbing two flights of stairs) without symptoms, as further tests rarely change management.

## At what blood pressure is elective surgery usually postponed?

At around 180/110 mmHg or above; below that, surgery usually proceeds and antihypertensive treatment is continued.

[Add to my cards (4)](https://durgical.app/estudiar/?add=/en/anaesthesia/cardiac-risk-before-non-cardiac-surgery/)

## Elsewhere in DurgiPedia

- [Reading an ECG step by step](https://durgical.com/en/clinical-skills/reading-an-ecg-step-by-step/)
- [Echocardiography: transthoracic and transoesophageal](https://durgical.com/en/clinical-skills/echocardiography-transthoracic-and-transoesophageal/)
- [Murmurs: timing, grade, location and radiation](https://durgical.com/en/clinical-exam/murmurs-timing-grade-location-and-radiation/)
- [Muscle blood flow and the cardiovascular response to exercise](https://durgical.com/en/physiology/muscle-blood-flow-and-the-cardiovascular-response-to-exercise/)

## Connections

## Related 5

- [The pre-anaesthetic visit: history, examination and tests](https://durgical.com/en/anaesthesia/the-pre-anaesthetic-visit-history-examination-and-tests/)
- [ASA physical status classification](https://durgical.com/en/anaesthesia/asa-physical-status-classification/)
- [Which medicines to continue or stop before surgery](https://durgical.com/en/anaesthesia/which-medicines-to-continue-or-stop-before-surgery/)
- [Anticoagulants, antiplatelets and neuraxial blocks](https://durgical.com/en/anaesthesia/anticoagulants-antiplatelets-and-neuraxial-blocks/)
- [The patient with heart disease having non-cardiac surgery](https://durgical.com/en/anaesthesia/the-patient-with-heart-disease-having-non-cardiac-surgery/)

## Related conditions 6

- [Myocardial Infarction (Heart Attack)](https://durgical.com/en/conditions/myocardial-infarction/)
- [Heart failure](https://durgical.com/en/conditions/heart-failure/)
- [Aortic Valve Stenosis](https://durgical.com/en/conditions/aortic-valve-stenosis/)
- [Stable angina](https://durgical.com/en/conditions/stable-angina/)
- [Arterial hypertension](https://durgical.com/en/conditions/arterial-hypertension/)
- [Atrial fibrillation](https://durgical.com/en/conditions/atrial-fibrillation/)

## In Pharmacology 4

- [Beta blockers](https://durgical.com/en/pharmacology/classes/beta-blockers/)
- [Statins](https://durgical.com/en/pharmacology/classes/statins/)
- [Acetylsalicylic acid](https://durgical.com/en/pharmacology/acetylsalicylic-acid/)
- [Clopidogrel](https://durgical.com/en/pharmacology/clopidogrel/)

[← All of anaesthesia](https://durgical.com/en/anaesthesia/)

Educational content; it does not replace supervised training, your institution's protocols or the anaesthetist's or intensivist's decision. It contains no doses and no ventilator or infusion settings.

Sources: [Perioperative Cardiac Management](https://www.ncbi.nlm.nih.gov/books/NBK493196/) (StatPearls (NCBI Bookshelf), 2023); [Evaluation and Management of Perioperative Hypertension](https://www.ncbi.nlm.nih.gov/books/NBK557830/) (StatPearls (NCBI Bookshelf), 2026).

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Source: https://durgical.com/en/anaesthesia/cardiac-risk-before-non-cardiac-surgery/
License: CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/). Cite as: DurgiPedia (durgical.com), https://durgical.com/en/anaesthesia/cardiac-risk-before-non-cardiac-surgery/