Update Article

Preoperative Evaluation for Non-Cardiac Surgery

AK Ghosh

Abstract
Internists are frequently consulted to perform preoperative risk assessments on patient undergoing non-
cardiac surgery. Physicians need to assess the cardiac risk associated with the surgery, identify the patient’s
unique risk profile, recommend appropriate preoperative testing and make suitable recommendations. By a
focused history-taking, physical examination, and application of current evidence-based guidelines in cardiac
risk assessments, patients at high risk for complications at surgery can be identified and additional work-up
suggested. Effective preoperative recommendation includes an assessment of risk (cardiac and non-cardiac),
recommendations on medication adjustment, thrombo-embolic prophylaxis, and use of perioperative β
blockers. Prompt communication with the surgeon often enhances the quality of medical consultation and
ensures compliance. ©

INTRODUCTION procedures, identification of individual risk predictors

E ach year 10% of the adult population undergoes a
non-cardiac surgery. A third of these surgeries are
performed in the geriatric population who are at
increased risk for a cardiac event.1 The overall mortality
rate of all surgeries is 0.3%.2 For major surgeries, the
mortality rate is less than 1% in patients younger than
65 years, but increases to 5% for patients between 65
and 80 years. Death in the postoperative period in the
first 48 hours is mainly due to cardiac causes, while
death between 48 hours and 6 weeks is often due to
pneumonia, sepsis, pulmonary embolism, cardiac arrest
and renal failure.3
Internists are frequently consulted to perform
preoperative evaluation of patients. Evaluation of the
surgical patient often starts with a systematic approach
to history taking and performing a focused clinical
examination. An essential skill is the identification of
high risk patients, whose medical condition need to be
optimized considerably prior to surgery, as well as the
identification of those patients who need to be excluded
from an elective surgery. With improvements in risk
assessment and recent advances in anesthesia and
surgical techniques, the latter group of patients are rare
these days. Preoperative evaluation is a part of the core
curriculum in Internal Medicine training in the US and
several hospitals now have specialized preoperative
clinics to assess patients prior to surgery. In the current
article, we will review the current evidence for
assessment of cardiac risk prior to non-cardiac surgical
Assistant Professor of Medicine, Division of General Internal
Medicine, Mayo Clinic College of Medicine, Rochester,
Minnesota, USA 55905.
(cardiac and non-cardiac), determine appropriate
preoperative testing and measures to tailor the
perioperative recommendation to the patient’s medical
status.
Cardiac risks associated with Noncardiac surgery:
Cardiac risks of surgery include nonfatal myocardial
infarctions and fatal cardiac events. The incidence of
postoperative myocardial infarction(MI) in male general
surgery patients over 50 years is 0.7%, and is as high as
3.1% in vascular surgery patients. 4 The risk of
postoperative cardiac complication depends on the
functional capacity, presence of co-morbid conditions,
the age of the patient and the type of surgery.
The American Society of Anesthesiologist (ASA) have
stratified the surgical risk based on patient’s functional
state, co-morbid diseases, and urgency of surgery ( Table
1).5 The surgeries that are associated with high (> 5%)
cardiac risks include emergency major surgeries in
elderly, aortic and major vascular surgeries, peripheral
arterial procedures and surgeries of prolonged duration.
Intermediate risk surgeries (<5%) include carotid
endarterectomy, head and neck surgery, abdominal
surgery, intrathoracic surgeries, prostate surgery and
orthopedic surgery. Low risk surgeries (<1%) include
endoscopic procedures, breast surgery, cataract surgeries
and superficial procedures.6
The risk of mortality associated with anesthesia and
surgery has decreased from 1: 1500 in 1950 to 1: 250,000
more recently.7 The risk of perioperative myocardial
infarction is maximum 24 to 48 hours after surgery.3
Interestingly, 60% of perioperative myocardial
infarctions are not associated with chest pain. The
predictors of postoperative ischemia in patients

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 Table 1 : American Society of Anesthesiologists
classification of anesthetic risk
Class Physical status
I Normal healthy person < 80 years old
II Mild systematic disease
III Severe but not incapacitating systemic illness
IV Incapacitating systemic illness that is constant threat
to life
V Moribund patient unlikely to live > 24 hours,
regardless of surgery
E Emergency surgery, add suffix to any Class, i.e., IE,
IIE, etc.
48 hour mortality rate Class I-0.07%, Class II- 0.24%,
Class III- 1.4%, Class IV- 7.5%, Class V- 8.1%, E- double risk at
any class, modified from reference 5
undergoing non-cardiac surgery includes left ventricular
hypertrophy on EKG, history of hypertension, definite
coronary artery disease, diabetes mellitus and use of
digoxin.8 Hence postoperative monitoring should be
recommended in patients at high risk for ischemia.
Assessment of Cardiovascular risk
A focused history and physical examination is
essential to determine if the patient has any of the five
cardiac risks factors. These include ischemic heart
disease, valvular heart disease, congestive heart disease,
arrhythmias and hypertension.
A history of recent ischemic cardiovascular events is
associated with a dramatic increase in perioperative
myocardial infarctions (MI). In patients undergoing
surgery, the risk of perioperative MI is 37%, 16% and 5%
in patients with history of suffering from MI in the last 3
months, 3-6 months and over 6 months, respectively.9
Hence, routine surgeries must be delayed for at least 6
months after a MI. Recent advancement in anesthetic
delivery, post operative care, have allowed surgeries to
be performed as early as 4 to 6 weeks after an acute
myocardial infarction if preoperative stress testing reveals
an absence of myocardial ischemia.6 In high risk patients,
treatment with B-blockers started a few days prior to
surgery to achieve a heart rate of 50 to 60 beats/ min,
reduces the risk of subsequent cardiac events.10,11
Patients with valvular heart disease especially severe
aortic stenosis (AS), increases the risk of surgery. Patient
with severe AS have a fixed cardiac output and do not
tolerate either general or spinal anesthesia as they are
associated with vasodilatation. Patients with moderate
to severe mitral stenosis also tolerate surgery poorly. On
the other hand, patients with aortic and mitral
regurgitation with preserved left ventricular function are
less likely to have an adverse cardiac event due to the
valve dysfunction. Patients with valvular heart disease
will require appropriate infective endocarditis
prophylaxis.
History of preoperative congestive heart failure (CHF)
increases the risk of pulmonary edema from 3% in New
York Heart Association Class 1 to 25% in patients with
© JAPI • VOL. 53 • APRIL 2005 www.japi.org
Class IV CHF. However, in 50% of patients who develop
postoperative CHF, there is no prior history of CHF. Most
of these patients develop CHF within an hour of
completion of surgery and need aggressive postoperative
care with diuretics and medical co-management.12
Elective surgery should be postponed for atleast 1 week
after optimizing the signs of heart failure. On the
contrary dehydration should be avoided as hypovolemia
can result in hypotension during anesthesia.
Patients with arrhythmias may tolerate surgery
poorly. Patient with supra-ventricular arrhythmias need
to be rate controlled prior to surgery. Patients with
ventricular arrhythmias need to be evaluated by a
cardiologist prior to surgery. Those with first-degree
heart block and Mobitz Type I heart block tolerate
surgery well, though patients with Mobitz type II, third
degree heart blocking might require intraoperative
pacing.
Hypertension should be well controlled prior to
surgery. Studies have shown that if diastolic blood
pressure (BP) is maintained below 110 mm Hg, surgeries
can be performed without increased risk. The general
consensus is to have the systolic BP below 180 mm Hg
prior to induction of anesthesia. Antihypertensive agents
must be continued in the perioperative period and
occasionally parenteral anti-hypertensive medication
may be required if patient is unable to tolerate
medication by mouth or through a nasogastric tube.
Numerous risk assessment tools including the
American Society of Anesthesiologist score (ASA index)5,
Goldman’s cardiac risk index13, Detsky’s criteria14 have
been used to assess cardiac risks. Recent
recommendations by the American College of
Cardiology/ American Heart Association (ACC/AHA)
regarding perioperative cardiac evaluation is based on
clinical risk predictors, the functional status of the
patient, and risk of the surgical procedure (high,
intermediate or low risk).6 The clinical predictors of risk
are defined as major, intermediate, or minor, depending
on the severity of the ischemic heart disease and other
factors (Table 2). Functional status of a patient can be
determined by the ability of the patient to perform
household tasks and exercise activities.6 A patient who
is unable to climb a flight of steps (estimated energy
requirement of < 4 METs) has a poor functional status.
Patients with moderate functional capacity (4-7 METs)
can climb a flight of stairs but are unable to participate
in moderate activities such as bowling, dancing, or
playing golf. Patients with good functional activities (>
7 METs) are able to participate in moderate recreational
activities.
Patients who have had coronary revascularization
procedure in the last 5 years or have had a favorable
coronary angiogram 2 years prior to surgery usually do
not require any further testing6. Noninvasive (stress test)
and/or invasive cardiac evaluations (coronary
307

Fig. 1 : Algorithm for individual risk assessment for noncardiac surgery* (modified
from reference 6)
angiogram) is required in patients with major clinical
predictors, those with intermediate clinical predictors
and poor functional capacity (4 METs) or undergoing
high surgical risk procedures, and in patients with
minor clinical predictors and poor functional capacity
undergoing high risk procedure (Fig. 1).
Assessment of Pulmonary risks
Pulmonary complications (pneumonia,
hypoventilation and atelectasis) occur in about one-third
patients postoperatively, and account for 50% of overall
mortality 15. Preoperative pulmonary testing is indicated
in patients with suspected lung disease, patients with
over 10 pack-year history of smoking, patients with
chronic obstructive lung disease (COPD). Forced
expiratory volume in 1 second (FEV1) is probably the
best indicator of surgical risk. Patients with FEV1 > 2 can
safely undergo surgery while patients with FEV1 of < 1
are at high risk of postoperative pulmonary
complication. Chest X-ray is recommended for patients
suspected of chronic lung disease, pulmonary
tuberculosis and those undergoing thoracic or
abdominal surgery. Arterial blood gas evaluation maybe
reserved for patients with severe COPD.
Preoperative precautions to decrease pulmonary risks
include smoking cessation, preferably several weeks
prior to surgery, use of bronchodilators and treatment of
chronic bronchitis. Postoperatively, for patients with
chronic lung disease, incentive spirometry,
bronchodilators, chest physiotherapy and early
mobilization are encouraged.
Preoperative Hematologic Risk Assessment
Patients should be assessed for increased bleeding
risks (use of non-steroidal anti-inflammatory agents,
hereditary or platelet factor disorders, clotting factors
308
Table 2 : Clinical predictors of risk for surgery
Predictors Examples
Major Decompensated CHF
Unstable coronary syndromes
Significant arrhythmias
Severe valvular diseases
Intermediate Mild angina pectoris (Class I/II)
Compensated or prior CHF
Prior MI by history and Q waves
Diabetes mellitus
Renal insufficiency
Minor Advanced age
Abnormal EKG (RBBB, LVH, ST-T
abnormalities)
Rhythm other than sinus
Low functional capacity
History of CVA
Uncontrolled blood pressure
Abbreviations- CVA- cerebrovascular accidents,
CHF- congestive heart failure, RBBB- right bundle
branch block, MI- myocardial infarction, LVH- left
ventricular hypertrophy, Modified from reference 6.
deficiency, or on anticoagulants). NSAIDs like aspirin
should be discontinued one week prior to elective
procedures. Warfarin should be discontinued 5 days
prior to elective procedures. Most surgeries can be
performed safely at an INR (international normalized
ratio) of < 1.5. Patient with mechanical prosthetic valves
undergoing surgery should discontinue Warfarin several
days prior to the procedure and managed with low-
molecular weight heparin (LMWH). LMWH can be
discontinued 12 to 24 hours prior to surgery and
restarted postoperatively along with warfarin when it
is considered safe. A hematologist must be involved in
the care of the care of patients with hereditary or platelet
factor disorders, clotting factors deficiency.
Surgical patients at high risk for venous
thromboembolism (TE) include those who are obese,
elderly, undergoing prolonged operations or hip surgery,
history of malignancy, previous TEs, hereditary
disorders of thrombosis, or use estrogen. These patients
require TE prophylaxis with measure such as the use of
LMWH, unfractionated heparin, or warfarin, early
mobilization and intermittent pneumatic compression
devices.16
Endocrine aspects of risk assessment
Common endocrine conditions that impact
perioperative risk includes diabetes mellitus, thyroid
disorders and secondary adrenal insufficiency due to
prior corticosteroid use.
Patients with poorly controlled diabetes are more
prone to developing wound infections. Hence, it is
desirable to have at least moderate blood sugar control
preoperatively. Patients on oral hypoglycemic agents
should hold their medication on the morning of surgery.
Metformin should be held 48 hours prior to surgery and
Chlorpropamide (due to prolonged half-life) should be
www.japi.org © JAPI • VOL. 53 • APRIL 2005
held 48-72 hours prior to surgery. On the morning of
surgery, regular insulin should be held, and one-half
the dose of NPH insulin must be administered. Routine
autonomic function tests are not indicated
preoperatively, though patients with autonomic
disorders should be carefully monitored in the
intraoperative and postoperative period for
hemodynamic change and hypothermia. Underlying
cardiovascular disorder may also complicate the
preoperative assessment in diabetic patients. Recent
studies on retrospective observation study in patient
undergoing cardiac surgery, indicate that patient with
higher intraoperative hyperglycemia might have
increased complication of atrial fibrillation, cardiac
arrest, pneumonia , urinary tract infection developing
with 30 days of cardiac surgery.17 A 20 mg/dl increase
in mean glucose level was associated with a 30%
increase in adverse outcome.17 Serum glucose should be
maintained below 150 mg/dl in the postoperative
period.
Patient with hypothyroidism present low surgical risk
and should continue on their regular thyroid
replacement dosage. Uncontrolled hypothyroidism may
result in delayed clearance of anesthetic agents. Patients
with uncontrolled thyrotoxicosis are at high surgical
risk of thyroid storm, hence elective surgery should be
postponed for at least 3 months or until the patient in
euthyroid. In case of emergency surgery in a patient with
thyrotoxicosis, pretreatment with propranolol and
propylthiouracil is recommended.
Secondary adrenal insufficiency must be suspected
in patients who have received long-term steroid therapy,
or those that have received at least 2 weeks of steroids in
the previous year. These individuals should be covered
with replacement doses of corticosteroids in the pre- and
peri-operative period.18
Nutritional Status and Surgical outcome
Malnutrition and hypoalbuminemia has been
associated with postoperative morbidity and mortality.
A decrease of serum albumin from greater 4.6 g/dl to
less than 2.1 g/dl was associated with an increase in
mortality from <1% to 29%, and increase in morbidity
from 10% to 65%. 19 Patient who are severely
malnourished (> 15% loss of body weight), might benefit
from preoperative nutritional intervention.20
Risk assessment of other organ systems
Patients with chronic liver disease are at high risk of
delayed clearance of anesthesia and prolonged
intubation. These patients require a baseline assessment
of prothrombin time and partial thromboplastin time
assays and need to be monitored for bleeding
complications.
Patients with renal insufficiency require close
monitoring to prevent hypotension, fluid and electrolyte
imbalances and antibiotic nephrotoxicity. Patients with
end-stage renal failure undergoing surgery may need
© JAPI • VOL. 53 • APRIL 2005 www.japi.org
dialysis 12 hours preoperatively and 12-24 hours
postoperatively, to optimize fluid and electrolyte balance.
Elective surgery should be postponed in patients with
severe acute infections.
Role of routine pre-operative laboratory testing
Laboratory testing is rarely indicated in patients under
the age of 50 years. For patients over 50 years, minor
abnormality of laboratory tests rarely delays surgery.21
When indicated, specific tests should be planned based
on the clinical history of the patients. In the past, chest
X-rays were done on all patients undergoing surgery
due to the high prevalence of undetected pulmonary
tuberculosis. However, current day indication of chest
X-ray is limited to patients over 60 years, or those with
known pulmonary symptoms or with cardiac disease.
The current recommendation of routine laboratory
testing is summarized in Table 3.
Table 3 : Indications of Routine Pre-operative tests in
adults undergoing elective surgical procedures
Tests Indications
Hematocrit All women, men > 60 yrs, anticipated
blood loss
Electrolytes Patients > 60 yrs, diabetics, renal and
liver disease, patients on diuretics
Urinalysis Recommended only for prosthetic joint
Placement surgeries
Protime and partial Patient with liver disease, anti-
thromboplastin time coagulated patients, malignancy,
neurosurgical procedures
Chest radiograph Patients >60 yrs, patients with cardiac
and pulmonary disorders
Electrocardiogram All men older than 40 yrs and women
over 50 years, all diabetics and patient’s
with history of heart disease
Management of chronic outpatient medications
Elderly patients account for one-third of all surgeries,
and half of all emergency procedures. Most elderly
patients have one or more concomitant chronic medical
disorder and are on numerous medications. Physicians
have to be aware of the medication adjustments and
suggest appropriate medication modifications to avoid
perioperative complications. 22 Table 4 outlines the
appropriate management of commonly prescribed
medications.
Preoperative templates and recommendations
The purpose of preoperative evaluation by internists
includes an assessment of the cardiac and noncardiac
risk factors for surgery, recommendation for appropriate
testing, assessment of fitness for surgery and
recommendations for perioperative medication such as
â blockers and venous thromboembolism prophylaxis.
The mnemonic (A to I) could be helpful in summarizing
the history of a preoperative evaluation. A- allergies, B-
bleeding tendencies, C- coronary artery disease, CHF,
COPD, D- list of drugs, E- endocrine including thyroid
309
Table 4 : Medication adjustments and recommendations- Table 5 : Template for preoperative assessment and
prior to elective surgery recommendations
Medication Perioperative modification 1 ) Type of surgery planned: elective, emergency
2 ) History of presenting illness
Antihypertensives Take on the morning of surgery
a ) History of CAD : None, Class I, Class II, Class III,
(exception of diuretics)
Class IV
Digoxin Check digoxin level. Take on morning
b) History of CHF : None, Class I, Class II, Class III,
of surgery
Class IV
HMG CoA reduction Hold prior to surgery. Increase
c) Pulmonary disease : None, COPD, asthma, smoking,
and Gemfibrozil risk of rhabdomyolysis pulmonary tuberculosis
NSAIDs – d) Diabetes mellitus : None, Type I, Type II
Aspirin, NSAIDs Hold 1 week prior to surgery e) Renal disease : None, Yes
Clopidogrel Hold 5 days prior to surgery
f) Functional status : Poor, Moderate, Good
Warfarin Hold 3-5 days prior to surgery
i) Bleeding risk : None, Yes
Oral hypoglycemic agents
j) Prior hepatitis or blood transfusion : Yes, None
Metformin Hold 2 days prior to surgery
Chlorpropamide Hold 2-3 days prior to surgery k) Venous thromboembolism risk : None, Yes
Newer oral Hold on the morning of surgery l) Prior anesthesia complications : Yes, None
hypoglycemic m) History of aspirin use : Yes, None
Insulin- Regular Hold on morning of surgery n) History of recent steroid use : None, Yes
NPH ½ dose on the AM of surgery o) History of alcohol dependence : None, Yes
Bronchodilators Take prior to surgery 3 ) Medication and allergy list
Thyroid replacement Take prior to surgery 4 ) Focused review of systems : prior CABG, cardiac stress
Sedatives Hold on morning of surgery, reassess test (last 2 years)
further use in postoperative period 5 ) Vitals signs and focused examination : BP, Pulse, JVP,
Hypnotics Hold on morning of surgery, reassess carotid bruits, S3, severe aortic stenosis, lung sounds, active
further use in postoperative infection
Estrogen Discontinue prior to surgery 6 ) Impression, Recommendations and Plan :
Herbal medication Discontinue prior to surgery a ) Cardiac risk for noncardiac surgery : Low risk (< 1%),
intermediate risk (< 5%), high risk procedure (> 5%)
b) Patients Clinical risk predictors : None, minor,
status, diabetes mellitus and corticosteroid use, F- family intermediate, major
history of malignant hyperthermia, G- glaucoma, H – c) Results of laboratory test- summarize
hepatitis, HIV and I – infections (Tuberculosis or active d) Fitness for surgery : Yes, No (require additional
infection). Internist should avoid using the term, ‘okay evaluation)
for surgery’. The plans regarding the type and mode of e) If fit for surgery, additional recommendations : β
blockers, DVT prophylaxis, medication adjustments,
anesthesia, and the decision to proceed with surgery is
delirium risk
a shared decision, to be made by the surgeon, the
anesthetist and the patient. CAD- coronary artery disease, CHF- congestive heart failure,
COPD- chronic obstructive pulmonary disease, JVP- jugular
Several hospitals use templates to perform a venous pressure
preoperative evaluation. We have summarized a
template for preoperative assessment in Table 5. High who are likely to benefit from β blockade include those
risk patients requiring additional evaluations, i.e. stress with history of known coronary artery disease (history
testing or coronary angiogram can be identified quite of myocardial infarction, angina, positive exercise stress
easily using this format.6 It is important to note that test) and suspected coronary artery disease (having 2 or
patient is never subjected to coronary angiogram and more of these risk factors, age > 65 yrs, hypertension,
coronary bypass surgeries just to ‘get through the nicotine dependence, diabetes mellitus, cholesterol > 240
surgery.’ These procedures are often indicated mg/dl).11 These patients would benefit from the initiation
independent of the elective surgical procedure. of Atenolol 50 mg on the day of surgery and continued
Additionally, in patients who have undergone coronary up to one week postoperatively, or until discharge. The
artery stenting, surgery is deferred for several months as benefit from the use of â blockade on reduction in cardiac
the risk of postoperative mortality and morbidity is risk has been noted to last for at least 2 years
higher in this group of patients in the months postoperatively.
immediately following the coronary artery stenting Hence, by adhering to structured history taking and
procedure. Often these patients are on Clopidogrel performing a patient focused examination, an efficacious
(Plavix), which can increase the risk of postoperative preoperative evaluations can be performed in a
bleeding. reasonable and timely fashion. Internists can provide
Recent studies have demonstrated that in select valuable assistance to their surgical and anesthesia
patients at high risk for coronary artery disease, use of â colleagues by evaluating and coordinating the care of
blockers can reduce the incidence of preoperative patients scheduled to undergo surgery. The internist
mortality and myocardial infarction by 50%.10 Patients must communicate effectively to their referring

310 www.japi.org © JAPI • VOL. 53 • APRIL 2005

physicians in a summary statement that comprises the
patient’s risk assessment, and appropriate perioperative
recommendations.
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Announcement
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