Perioperative Cardiology — Cardiology Guide

Key
decisions

Unstable?ACS, decompensated HF or unstable arrhythmia → stabilize and decide timing. Emergency surgery proceeds as required with parallel treatment.

Low-risk pathway?Low combined risk, low-risk surgery or adequate capacity with stable symptoms → usually no routine coronary testing.

Make the decision

six questions, one recommendation

1 · Clock + stabilityEmergency / urgent / time-sensitive / elective. Operation, harm of delay and active disease.

2 · Risk + reserveValidated estimate, valve/RV/PH/device modifiers and actual functional capacity.

3 · Test + actOrder only if a result changes treatment, timing or monitoring.

Proceed • optimize • defer

state the condition

Proceed Explain residual risk. A normal test does not guarantee an uncomplicated operation.
Optimize or defer Name the disease to treat, reassessment criterion and acceptable surgical window.

Before surgery Medication last doses, anticoagulation/PCI constraints, device plan and hemodynamic goals.
After surgery Monitoring, event response, restart criteria and follow-up owner.

Address independent cardiac disease even when testing stops. Open-heart surgery → Valve and CABG Workups.

Guideline currency: AHA reaffirmed the perioperative guideline in September 2026 without changing the 2024 recommendations. Dates attached to trials and other society documents remain source-specific.

Define the harm of waiting before choosing the workup.

How much time is available?

surgeon defines the actual deadline

Urgency	Window	Action
Emergency	Usually <2 hours	Focused assessment + stabilization while required surgery proceeds. Plan anesthesia and recovery location.
Urgent	Usually 2 to <24 hours	Resolve immediate threats. Avoid tests reporting after the decision deadline.
Time-sensitive	Potentially up to 3 months	Name the latest acceptable date. Balance cardiac benefit against surgical harm from delay.
Elective	Time for treatment	Evaluate and treat important disease before fixing the operative date.

Procedure burden Confirm approach, blood loss/fluid shifts and anesthesia.

Active disease changes the pathway

treat within the clock

ACS New/accelerating ischemic symptoms, acute ischemic ECG changes or suspected infarction.
Decompensated HF New congestion, resting dyspnea, hypoperfusion or deterioration from baseline.

Dangerous rhythm Sustained ventricular arrhythmia, high-grade block, symptomatic bradycardia or unstable tachyarrhythmia.
Major lesion Severe symptomatic valve disease or another hemodynamic constraint → define severity and treatment options.

Timing implications

acute versus stable

Elective Treat acute cardiac disease before proceeding when appropriate.
Urgent Joint stabilization-versus-delay decision with surgery/anesthesia.
Recent MI Review date, mechanism, treatment, symptoms and ventricular function. No universal 30-day rule.
Stable history Remote MI, stable HF and controlled arrhythmia do not equal active disease.

Quote the model, endpoint and time horizon. RCRI points are not a universal event percentage.

Risk and reserve

two different questions

Combined MACE risk

<1% / ≥1%

Low / elevated risk

Poor capacity

DASI ≤34 or <4 METs

DASI >34 supports better reserve

Model	Use	Limit
RCRI	Six clinical predictors	Cardiac-complication categories are not interchangeable with other MACE estimates.
Gupta MICA	Procedure-specific MI/cardiac arrest	Verify operation, functional status, ASA, age and kidney input.
ACS NSQIP	Cardiac + noncardiac complications	Exact procedure and inputs. Each output answers a different question.

RCRI inputs Ischemic heart disease, HF, cerebrovascular disease, insulin-treated diabetes, creatinine >2.0 mg/dL and qualifying high-risk surgery.

Interpret the patient outside the score

capacity + modifiers

Verify Use the validated instrument. Never impute creatinine, count all diabetes as insulin-treated or import another cohort’s event rate.
Capacity Actual activity, recency and limiting symptom. Knee pain means uncertain capacity, not ischemia. Avoid unsupported >4-MET claims.

Modifiers Severe valves, PH/RV dysfunction, recent PCI/stroke, congenital disease, device/LVAD and frailty.
Frailty Validated assessment in older/apparently frail patients facing elevated-risk surgery informs recovery/support.

Better DASI does not override acute symptoms or a severe lesion.

Order only when a result changes care. Define abnormal, reassuring and inconclusive result branches.

Choose the test

use / avoid

Test	Use	Avoid
ECG	Relevant CVD/symptoms before elevated-risk surgery. New rhythm/ischemic concern.	Routine asymptomatic low-risk screening.
TTE	New dyspnea/HF, suspected new or worsening dysfunction, important valve question.	Routine EF recheck in stable asymptomatic patients.
BNP/NT-proBNP	Selected higher-risk patients.	Coronary localization or automatic angiography.
Baseline troponin	Selected risk refinement or planned injury surveillance.	Single-value ACS diagnosis.
Stress imaging	Elevated procedural/clinical risk + poor/unknown capacity + actionable result.	Age, diabetes or RCRI point alone.
CCTA	Selected actionable high-risk anatomy question.	Universal screening or incidental-calcium reflex.
Angiography	Independent indication or concerning finding with a treatment question.	Routine preoperative step.

Biomarker selection

AHA/ACC

Candidates Elevated-risk surgery + known CVD, age ≥65, or age ≥45 with CVD symptoms. BNP/NT-proBNP reasonable, troponin optional.

BNP

>92 ng/L

Algorithm risk flag

NT-proBNP

≥300 ng/L

Algorithm risk flag

Troponin

>99th percentile

Assay upper reference limit

Interpretation Risk flags, not cancellation values. Review kidneys, chronic HF, rhythm and trajectory → cause, optimization and surveillance. An elevated biomarker alone does not establish obstructive CAD or require catheterization.

Match the modality

question + feasibility

Stress/CCTA branch Elevated procedural/clinical risk, poor/unknown capacity and management-changing result.

Choose for feasibility Exercise ability, image quality, rhythm, kidney function and expertise. Unstable patients need active-disease assessment, not routine stress testing.

Revascularization needs a clinical indication. PCI may delay the operation.

Treat CAD for the right reason

indication before procedure

Treat ACS pathway. Left-main ≥50% → consider revascularization and elective deferral.
Avoid Routine non-left-main intervention solely to reduce operative risk.

CARP 510 stable vascular-surgery patients. Mortality 22% versus 23% at 2.7 years. No postoperative MI benefit.
Delay 54 versus 18 days: revascularization versus no revascularization. Weigh benefit against antiplatelet-related delay.

Surgery after PCI

DES anchors assume ≥1 antiplatelet interruption

PCI context	Timing anchor
Balloon without stent	Elective delay ≥14 days
DES for ACS	Ideally elective delay ≥12 months
DES for chronic CAD	Elective delay ≥6 months reasonable
DES, time-sensitive surgery	Consider ≥3 months if delay causes more harm
BMS/DES within 30 days	Elective antiplatelet interruption potentially harmful

Early time-sensitive surgery Within 30 days of BMS or <3 months of DES: continue DAPT unless bleeding outweighs protection.
Aspirin after PCI Continue low-dose aspirin if feasible. Crossing a time threshold does not eliminate thrombosis.

If interruption is authorized

surgery + anesthesia + interventional cardiology

Recovery intervals Aspirin 4 days • clopidogrel 5-7 days • prasugrel 7-10 days • ticagrelor 3-5 days. Neuraxial/deep-block rules may be longer.
No PCI Weigh secondary-prevention benefit against bleeding. Avoid routine initiation. POISE-2: no overall death/MI benefit, more major bleeding.
Handoff PCI date/indication/anatomy, agents, last doses, restart trigger/owner. Heparin cannot replace stent antiplatelet protection.

POISE-2 is not a blanket post-PCI stop rule. Populations and limits → CABG/PCI evidence.

Plan the entire gap: last dose → protection → procedure → restart.

Elective anticoagulant anchors

not neuraxial safety intervals

Agent	Interruption / restart	Modifiers
Factor Xa DOAC	Usually omit 1 day for low/moderate, 2 days for high bleed risk	Minimal risk may need less. Renal dysfunction, interactions and blocks can extend timing.
Dabigatran	Usually omit 1–4 days	CrCl + procedural bleeding risk
Warfarin	Usually stop ~5 days, verify INR	Some minor procedures permit continuation. Very high thrombosis risk needs specialist review.
DOAC restart	~24 hours low/moderate, 48-72 hours high risk	Hemostasis, renal trajectory and catheter requirements

Count actual doses CHEST/PAUSE omitted days are not exact elapsed hours. Two omitted days need not equal 48 hours.

Bridge only when justified

indication + event date

Usual branch DOACs generally need no bridge. BRIDGE supports avoiding routine warfarin bridging in its AF population.
Limit BRIDGE does not settle mechanical valves or every very-high-risk patient.

Review individually Mechanical mitral/older valves, very recent stroke/systemic embolism, recent VTE or LV thrombus.
Guideline differences Exceptional-risk recommendations differ. Agree with anticoagulation/procedural teams rather than bridging a whole diagnostic category.

Apply the second clock

ASRA + anesthesia

Blocks/catheters Drug, dose, CrCl, needle placement, catheter removal and subsequent dosing determine neuraxial/deep plexus/peripheral-block intervals.
Complete order Agent/dose/indication, last doses, CrCl, bleeding risk, valve/event history, bridge if selected, procedure checks, prophylaxis and restart conditions/owner.

Antiplatelet interruption is separate. Agent-specific holds and urgent reversal → medication guide.

Indication and current physiology determine continuation. Every hold needs a restart condition.

Cardiovascular medications

before / after

Drug	Before surgery	Reassess before dosing
Beta blocker	Continue established therapy when appropriate. New indication: start optimally >7 days before, not routinely on operative day.	Bradycardia, hypotension, perfusion
Statin	Continue if agent, liver status and interactions permit. Start for a long-term indication.	Rosuvastatin contraindicated in acute liver failure/decompensated cirrhosis
ACEi/ARB	Controlled hypertension + elevated-risk surgery: consider omission 24 hours before. HFrEF: continuation reasonable if tolerated.	BP/perfusion, K, kidney trend
ARNI	Explicit HF/anesthesia plan: indication, BP, kidneys	Tolerance/dose. ACEi↔ARNI switch requires 36 hours
Diuretic	Congestion versus depletion, fasting, anticipated shifts	Examination, I/O, weight, renal/electrolyte trends
MRA	K, kidney function, anticipated instability	Continue/restart only if K/kidneys permit
Clonidine / rate drugs	Prevent withdrawal. Check additive bradycardia/hypotension	NPO route + hemodynamic tolerance

Evidence and exceptions

STOP-or-NOT

Trial 2,222 patients. Death/major postoperative complications: 22% with either ACEi/ARB strategy.
Hypotension Vasopressor-treated: 54% continuation versus 41% interruption. Few HF patients. No universal HFrEF/ARNI hold.

Source scope Beta blocker/statin/ACEi/ARB branches follow guidelines. Diuretic/MRA/ARNI orders remain individualized.
No reflex initiation Surgery alone does not indicate aspirin, beta blocker or clonidine. New therapy needs indication and follow-up.

Calendar last dose + physiologic restart gate + owner. Reassess after bleeding, hypotension, AKI or prolonged fasting. Details → medication guide.

Key
decisions

SGLT2 holdScheduled surgery: canagliflozin/dapagliflozin/empagliflozin ≥3 days, ertugliflozin ≥4 days. Applies to HF and diabetes.

Type 1 diabetesPreserve basal insulin during fasting. Specify dose/infusion and monitoring.

SGLT2: detect and recover

normal glucose does not exclude ketoacidosis

Urgent/incomplete hold Alert anesthesia/inpatient teams. Fasting, illness and depletion increase concern.
Suspected ketoacidosis Check acid-base status and ketones even without marked hyperglycemia.

Restart Clinical stability, reliable intake, volume/metabolic recovery, insulin delivery and resolved ketoacidosis concerns. Name owner.
Label gate Empagliflozin resumption requires clinical stability and resumed intake.

Glucose plan

ADA 2026

Perioperative glucose

100-180 mg/dL

Individualized insulin and glucose checks

Operative day

Hold oral agents

Includes metformin

Guidance update ADA 2026 differs from the 2024 cardiac guideline permitting metformin continuation. Reconcile with anesthesia/diabetes teams.

GLP-1 / dual GIP-GLP-1

aspiration risk

Assess Agent/dose, escalation, GI symptoms and other delayed-emptying conditions. Low-risk patients may continue under multisociety guidance.
Higher risk Anesthesia-led diet, fasting, ultrasound/airway or deferral plan.
Keep sources distinct Multisociety: selective ≥24-hour liquid diet. SPAQI continuing users: 24 hours of clear liquids plus modified liquid fasting.
Pitfall A weekly drug held 7 days does not establish an empty stomach.

Communicate the hemodynamic constraint, not just the EF.

Lesion → decision → physiology

anesthesia handoff

Finding	Before surgery	Key constraint
Decompensated HF	Treat congestion/hypoperfusion. Reconsider elective timing.	Current volume/perfusion, support needs, reassessment
Stable HF	Optimize within the window. Plan drugs/monitoring.	Baseline function, volume target, BP tolerance, recovery
Severe AS	Symptoms/LV function → need for intervention before elective surgery	Fixed outflow: rhythm, preload, perfusion, monitoring
Severe MS	Symptoms, obstruction, rhythm, PA pressure → treatment options	Tachycardia and excess filling pressure
Important MR/AR	Severity, ventricular response, independent intervention indication	Reserve and loading/rhythm goals
Obstructive HCM	Current obstruction/symptoms → anesthetic plan	Avoid tachycardia and abrupt preload/afterload reduction

Interpret reserve

symptoms + loading + trajectory

HF review Symptoms, recent admission, volume, LV/RV, valves, BP, kidneys and treatment response. HFpEF is not low risk by EF alone.
Discordance Verify technical quality, flow and complete study. One gradient cannot establish valve severity.

AS exception Asymptomatic moderate/severe AS, normal LV systolic function, appropriate echo within 1 year → elective low-risk surgery may proceed.
Higher-risk AS Symptoms or elevated-risk surgery need fuller valve/timing review. Severe AS does not prohibit every operation.

Example: fixed outflow obstruction → avoid an abrupt fall in perfusion pressure. A specific mechanism directs anesthetic care.

High echo PA pressure is a clue. Classify the mechanism and assess the RV.

Define the physiology

before treatment

Mechanism Pulmonary vascular, left-heart, lung or chronic thromboembolic disease.
Reserve Symptoms/function, oxygenation, RV findings, recent decompensation, current therapy and relevant invasive hemodynamics.

Treatment boundary PAH drugs are not the default for every elevated PA pressure.
Specialist question New vasodilator or invasive test needs a defined purpose. Involve PH expertise for significant disease.

Protect the RV

optimize • deliver • rescue

1 · OptimizeReversible contributors within the surgical window. Avoid hypoxemia, hypercapnia, acidosis and deterioration.

2 · Maintain therapyPrescribed PH drugs. Continuous prostacyclin requires uninterrupted delivery and a contingency plan.

3 · Plan supportAnesthetic goals, volume/perfusion targets, invasive monitoring, recovery location and rescue.

Fluid pitfall Both depletion and excessive loading can harm. Avoid a generic bolus for every low BP.

Other major modifiers

outside routine calculators

Complex circulation Moderate/complex congenital disease or LVAD → specialist anatomy/device, anticoagulation, monitoring and troubleshooting plan.
Recent stroke/TIA Elective delay ≥3 months is reasonable under AHA/ACC. Verify event and weigh harm of waiting.

Key
decisions

Unstable tachyarrhythmiaStabilize immediately. Treat the cause as well as the rate.

Stable AFRate/rhythm strategy + anticoagulation plan. Postoperative AF needs trigger, recurrence and stroke-prevention review.

Six CIED answers

before electrosurgery

Domain	Required answer
Device	Pacemaker/ICD/CRT/leadless, manufacturer/model, team contact
Function	Recent review, battery/function, dependence, underlying rhythm
Procedure	EMI, field, position and generator access
Intervention	Programming or verified magnet response, pacing mode, tachytherapies
Protection	Monitoring + external pacing/defibrillation + responder
Restoration	Owner, settings/therapies restored, postoperative function verified

Magnet and rhythm pitfalls

verify the actual system

ICD magnet Usually inhibits tachytherapies without asynchronous pacing. Dependence + anticipated EMI may require reprogramming.
Model/position Verify response and secure placement throughout surgery. Leadless systems need model-specific planning.

Rhythm review Rate, symptoms, conduction, QT drugs and electrolytes.
Recovery Monitor until planned settings/ICD therapies return. Document restoration before discharge.

Plan goals, monitoring and response before the operation.

Hemodynamic targets

individualize above the floor

Perfusion floor

MAP ≥60-65

mm Hg

Alternative floor

SBP ≥90

mm Hg

Selected deferral

BP ≥180/110

mm Hg, context required

Severe hypertension Selected CV-risk patients with recently poorly controlled BP and elective elevated-risk surgery: consider deferral. Verify measurement/context.
Target-organ injury Acute injury changes urgency. Individual physiology may need higher perfusion targets.

Specify the recovery resources

clinical indication, not an RCRI point

Volume/oxygen delivery Baseline volume target, expected loss, HF/RV constraints, oxygenation and anemia plan.
Monitoring What, duration, recovery location, escalation triggers. Select arterial line/telemetry/higher acuity for clinical/procedural need.

Drug/device recovery Restart conditions, laboratory review and restoration of settings.
Hypotension Treat promptly. Distinguish bleeding, vasodilation, ischemia, rhythm and RV failure. Focused echo may clarify unexpected instability when expertise is available.

Selective troponin surveillance

AHA/ACC option

When Consider 24- and 48-hour testing after elevated-risk surgery with known CVD, CVD symptoms, or age ≥65 plus CV risks.
Not routine Low-risk surgery without ischemic symptoms/signs does not warrant routine screening.
Action plan Same assay, available baseline, named reviewer and response. Suspected events need immediate assessment regardless of scheduled draws.

Troponin identifies injury. Mechanism determines treatment.

Name the phenotype

injury versus ischemia

Original decision schematic. A moving highlight follows the questions, not a treatment timeline. Treat instability immediately. Type 2 MI requires evidence of ischemia.

A rise or fall in troponin supports acute myocardial injury. A persistently elevated, stable concentration supports chronic injury. Interpret the trend with assay characteristics and the clinical setting.

MINS Injury within 30 days of noncardiac surgery attributed to presumed ischemia, with or without MI symptoms/signs. Exclude a clearly nonischemic cause. MINS can occur without meeting MI criteria.
Other causes Sepsis, PE, acute HF, stroke and chronic elevation need separate assessment. MINS does not exclude acute plaque disease.

Respond to the event

stabilize → classify → act

1 · AssessSymptoms, ECG, BP/perfusion, bleeding, oxygenation and troponin trend. Stabilize.

2 · Find mechanismIschemic evidence and cause. Echo/targeted tests for consequential uncertainty. Type 2 MI still requires ischemia.

3 · EscalateSTEMI, persistent ischemia, shock or dangerous rhythm → urgent cardiology/surgical review. Account for fresh-wound bleeding.

Supply-demand injury Correct contributors and define the remaining CAD question.
Before discharge Diagnosis, risk reduction, medication decisions and named follow-up.

Avoid automatic treatment

MINS and postoperative AF

MANAGE Dabigatran reduced major vascular events in selected MINS patients. Not every troponin elevation warrants anticoagulation.
Selection Bleeding, kidneys, other antithrombotics, procedural restrictions and local prescribing rules.

Postoperative AF Correct pain, volume disturbance, hypoxemia, infection and electrolytes. Match rate/rhythm therapy to stability and physiology.
AF follow-up Balance embolic and surgical bleeding risks. Review recurrence/anticoagulation even if sinus rhythm returns.

Recommendation first: proceed, optimize then proceed, or defer for a defined issue.

Decision and supporting facts

fill with verified findings

Operation [ ] Procedure • date • urgency • harm of delay
Recommendation [ ] Decision • reason • attached conditions • residual risk
Stability [ ] Symptoms • examination • active disease/relevant negatives

Risk [ ] Model • verified inputs • endpoint/result • modifiers
Capacity [ ] Structured activity • limitation • uncertainty
Testing [ ] None further / question • test • result-dependent action

Care plan

assign each open loop

Field	Required content
Timing / antithrombotics [ ]	PCI/event dates • last doses • agreed constraints
Medication [ ]	Drug/indication • actual final dose • NPO route • restart criteria/owner
Transplant [ ]	Graft/interactions • troughs • insulin/PAH delivery
Anesthesia / recovery [ ]	Hemodynamic goals • device • monitoring • location
Follow-up [ ]	Surveillance reviewer • restart owner • next review • change triggers

Patient and team handoff

one reconciled instruction set

Make executable Medication names/dates, final dose and restart authority. Clear contact/urgent-action instructions for chest discomfort, worsening dyspnea, syncope or significant change.
Show uncertainty Distinguish verified findings from proposals. Historical reassuring tests cannot establish current symptom status.
Final check Recommendation visible to surgery/anesthesia. PCI, anticoagulation, device and surveillance response explicit. No further testing still requires a care plan.

Four synthetic cases: identify the decision before ordering the test.

Testing and reserve

stable patients

Key
decisions

Cataract surgeryAsymptomatic, stairs limited by knee pain.

DecisionLow-risk surgery → no coronary stress test solely for poor mobility.

FinishVerify stability, independent concerns and medication/procedure instructions.

Key
decisions

Major abdominal surgeryTreated HFrEF, euvolemic, limited capacity.

DecisionVerify symptoms, calculate risk, consider selective biomarkers.

FinishBiomarkers may change counseling/optimization/monitoring without angiography. Coronary testing needs an actionable result.

Timing and myocardial injury

avoid shortcuts

Key
decisions

Cancer surgeryDES for ACS 6 weeks ago. Surgery cannot wait many months.

DecisionBefore the 3-month time-sensitive anchor and within preferred elective delay.

FinishSurgery/anesthesia/interventional review: delay harm, DAPT bleeding and thrombosis. No threshold guarantees safety.

Key
decisions

Postoperative sepsisElevated troponin.

DecisionSerial pattern → acute injury → ischemic evidence/MI criteria.

FinishReview ECG, symptoms and perfusion while treating illness. Sepsis + troponin alone establishes neither MINS nor type 2 MI/DAPT indication.