Preoperative Evaluation, Risk Assessment, and Optimization
Risk stratification
For cardiac surgery, use procedure-specific tools such as STS and EuroSCORE II, not the Revised Cardiac Risk Index, which was validated for noncardiac surgery. For noncardiac surgery in cardiac patients, define urgency, active cardiac conditions, functional capacity, and perioperative risk. Active conditions include unstable angina, decompensated heart failure, significant arrhythmia, and severe valvular disease. Functional capacity below 4 METs prompts careful judgment, not automatic testing; stress testing is useful only when results will change management. Biomarkers such as BNP and troponin and frailty scores refine risk but do not replace clinical assessment.
Optimization
Optimize heart failure with guideline-directed therapy, decongest if volume overloaded, correct anemia and coagulopathy, and control diabetes and hypertension without causing hypotension. Continue beta blockers in most patients, but avoid initiating high-dose beta blockade immediately before surgery. Manage antiplatelet agents with the surgical team according to stent type and bleeding risk; never stop dual antiplatelet therapy casually after recent coronary stenting. Use procedure-specific bridging decisions for anticoagulation. Evaluate pulmonary hypertension, sleep apnea, and renal function because they alter ventilation, drug clearance, and fluid tolerance. Obtain echocardiography for new dyspnea, murmur, or unexplained hemodynamic instability, not merely as a routine screen.
Traps
A frequent question trap is ordering a stress test that will not alter care, or delaying urgent surgery for a noninvasive test. Another is assuming a normal ECG excludes significant disease; symptoms may be masked by deconditioning or beta blockade. Worked example: a 72-year-old with a drug-eluting stent placed 3 months ago needs urgent colectomy. The decision is not a simple “stop DAPT”; involve cardiology and surgery, consider continuing aspirin, and balance stent thrombosis against bleeding. Rule of thumb: every preoperative test must have a defined action if abnormal.