cardiac testing. These guidelines also state that patients who have under-gone a coronary evaluation with favorable results within the past 2 years(such as a cardiac stress test or diagnostic cardiac catheterization) do not
Step 3. Determine the patient’s functional capacity.
Anassessment of functional capacity provides a context in which to viewany reported symptoms.Extremes of functional capacity (eg. very good or very poor) may influencedecision-making.
Step 2. Assess for any signs or symptoms of active cardiac disease.
Undiagnosed or unstable cardiac signs or symptoms require additionalevaluation and/or risk stratification before surgery.
Step 4. Estimate cardiac risk using an objective measure.
The Revised Cardiac Risk Index provides an objective measure of perioperative cardiovascular risk that can aid in decision-making (seetables 1and 2).
Step 5. Determine the urgency of the surgery.
Emergent surgery should not be delayed to allow for preoperativeassessment.In urgent surgery, the main objective is to identify unstable cardiacconditions which may require urgent treatment. Noninvasive testing israrely indicated prior to urgent surgery.
Step 6. Determine if additional testing is needed.
We usually reserve preoperative noninvasive stress testing for thefollowing situations:patients with signs or symptoms of undiagnosed or unstable cardiacdisease, orpatients with 3 or more of the RCRI undergoing intermediate- orhigh-risk surgery (see table 2).
Step 7. Incorporate appropriate risk reduction strategies.
Coronary revascularization is only rarely indicated in the preoperativesettingWe recommend prophylactic perioperative beta-blockers for patients whoare undergoing intermediate- or high-risk surgery with 2 or more of theRCRI predictors (see tables 1 and 2).
Step 1. Determine if the patient has recently undergone a cardiacevaluation or revascularization procedure.
Revascularization in the last 5 years usually precludes stress testing unlessthe patient presents with new signs or symptoms.Favorable results of non-invasive testing in the last 2 years usually makeadditional testing unnecessary.
Fig. 1. A stepwise approach to perioperative cardiovascular assessment and risk reduction.327