ACC/AHA guidelines for periop CV eval

The most recent ACC/AHA guidelines for perioperative evaluation and management were updated in 2014.

For pre-operative cardiac assessment of coronary artery disease, the decision to delay surgery for additional workup can be made by following the suggested steps:

Step 1: If it is an emergency, proceed to surgery.

Step 2: If the patient is having an acute coronary syndrome (ACS), then the patient should be referred to/discussed with a cardiologist for management of ACS prior to surgery.

Step 3: Estimate the risk of a major adverse cardiac event, (MACE), which can be estimated using the American College of Surgeons NSQIP risk calculator, or more commonly the revised cardiac risk index (RCRI).

Step 4: If MACE < 1%, the patient is at low risk, and you can proceed to surgery. Step 5: If the patient is not at low risk for a major adverse cardiac event, one must determine functional capacity.  If METs >4, proceed to surgery.

Step 6: If METs <4, or functional capacity is unable to be determined, and the patient not at low risk, then the team must determine whether or not further testing will impact the perioperative management and risk to the patient.  Consider stress testing, and, if abnormal, consider coronary angiography.

Other select pre-operative management guidelines:

Pre-operative EKG, with a level of evidence B:

  • There is no Class I recommendation for acquiring an EKG.
  • In a patient with known coronary heart disease, going for moderate or high risk surgery, there is Class 2a recommendation.
  • In patients without known heart disease, going for moderate to high-risk surgery, there is Class 2b recommendation.
  • There appears to be no benefit for asymptomatic patients going for low risk surgery

Pre-operative assessment of the left ventricle, with level evidence C:

  • There is no Class 1 recommendation.
  • With class 2a recommendation, guidelines state that it is reasonable to evaluate LV function in patients with dyspnea of unknown origin, or in patients with known heart disease with worsening dyspnea.

It is a class 1 recommendation to wait at least 14 days after a balloon angioplasty to undergo non-cardiac surgery, 30 days after BMS placement, and 365 days after DES placement.

It is a class 1 recommendation to continue beta blockade therapy in patients using them chronically.

In patients with 3 or more RCRI factors, with intermediate to high risk pre-operative testing, it may be reasonable to start beta blocker therapy; however, it should not be started on the day of surgery.

Alpha-2 agonists are not recommended for prevention of cardiac events.


Keyword history




  1. Fleisher LA et al. 2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Non-Cardiac Surgery. Circulation. 2014 Dec 9;130(24):2215-45. (PMID 25085962)

Defined by: Thaddee Valdelievre, MD