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Old MI: Preoperative risk assessment

For preoperative risk assessment, the age of a myocardial infarction (MI) is important. Acute MI is defined as occurring within the past 7 days. Recent MI is defined as happening between 7 and 30 days ago. Both acute and recent MIs, along with unstable angina, are considered unstable coronary syndromes and place the patient at considerably higher risk for a perioperative cardiac event. According to the 2014ACC/AHA Guidelines for Perioperative Cardiovascular Evaluation and Care for Non-Cardiac Surgery, the following conditions should prompt delay of elective non-cardiac surgery for further assessment and treatment:

Evaluate and Treat Before Elective Non-cardiac Surgery

  1. Unstable coronary syndromes
  2. Decompensated heart failure
  3. Significant arrythmias
  4. Severe valvular disease

Having an older MI (i.e. > 30 days ago) is a clinical risk factor for perioperative cardiac morbidity, falling under one of the variables of the (Lee) Revised Cardiac Risk Index.

Revised Cardiac Risk Index Variables:

  1. History of ischemic heart disease
  2. History of congestive heart failure
  3. History of cerebrovascular disease
  4. Insulin therapy for diabetes
  5. Preoperative serum creatinine > 2.0 mg/dL
  6. High-risk type of surgery

Unless the patient with an old MI has at least 2 more of the above risk factors, and either poor (<4 METs) or unknown functional capacity, surgery should proceed without further workup.


  1. T H Lee, E R Marcantonio, C M Mangione, E J Thomas, C A Polanczyk, E F Cook, D J Sugarbaker, M C Donaldson, R Poss, K K Ho, L E Ludwig, A Pedan, L Goldman Derivation and prospective validation of a simple index for prediction of cardiac risk of major noncardiac surgery. Circulation: 1999, 100(10);1043-9 PubMed Link

Other References

  1. 2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery Link
  2. Keys to the Cart for August 15, 2019 Link