Preoperative evaluation: American College of Cardiology Guidelines

The American College of Cardiology (ACC) and the American Heart Association (AHH) have collaborated to develop a set of clinical practice guidelines using scientific evidence in order to standardize the preoperative cardiac evaluation of patients undergoing non-cardiac surgery. Recommendations are based on a known history of or risk factors for cardiac disease as well as the urgency/risk of the procedure. Briefly, a few definitions are as follows:

  • Emergency procedure – life/limb is threatened if not in the OR within 6 hours, i.e. little to no time for clinical evaluation
  • Urgent procedure – limited time for clinical evaluation, life/limb is threatened if not in OR between 6 and 24 hours
  • Time-sensitive procedure – a delay > 1-6 weeks would negatively affect outcome
  • Elective procedure – could be delayed up to 1 year without risking outcome

Clinical risk factors for perioperative major adverse cardiac event (MACE) include the following:

  • Coronary artery disease – 8-fold increase in perioperative mortality rate if MI within 6 months of non-cardiac surgery. Data suggest should wait at least 60 days after an MI before noncardiac surgery (unless they had an intervention for the MI)
  • Heart failure, particularly if decompensated (S3, JVD, peripheral or pulmonary edema, rales)
  • Valvular heart disease – if moderate or greater, then should have a pre-op TTE within 1 year OR if significant change in clinical status then should have a TTE since that change occurred
  • Reduced functional status (< 4 METs)


Keyword history


Defined by:  Kathryn Kirkpatrick, MD