Preoperative cardiac evaluation for adults with known or risk factors for coronary artery disease

ACS: acute coronary syndrome; PCI: percutaneous coronary intervention; CABG: coronary artery bypass graft; RCRI: Revised Cardiac Risk Index; MICA: myocardial infarction or cardiac arrest; ACS-SRC: American College of Surgeons surgical risk calculator; DASI: Duke Activity Status Index; MET: metabolic equivalent; NT-proBNP: N-terminal pro-B-type natriuretic peptide; CCTA: coronary computed tomography angiography.

* Refer to UpToDate content on guideline-directed therapy for evaluation and follow-up after ACS, PCI, and CABG.

¶ Functional capacity can be assessed by asking patients to report their ability to perform activities of daily living either with standardized questions (eg, can you climb 2 flight of stairs) or, more formally, with a questionnaire (eg, the DASI questionnaire). The DASI consists of 12 weighted questions with a maximum possible total score of 58.2, with higher scores indicating better functional capacity. Perioperative risk is elevated in patients incapable of 4 METs during daily activity (eg, climbing ≥2 flights of stairs at a normal pace without stopping, or walking on level ground at 4 miles per hour) or with a DASI score ≤25. Refer to UpToDate content on perioperative risk assessment for further information on the DASI questionnaire.

Δ Test results may affect the patient's decision to undergo the planned surgery but may not affect care if the patient is unwilling to undergo treatment for abnormalities found on testing (eg, coronary revascularization after a positive stress test). Test results may also affect decisions about the extent or appropriateness of planned surgery, alternative treatment, perioperative monitoring, and/or perioperative medical management.

Δ Elevated NT-proBNP or BNP may be associated with increased perioperative cardiac risk and may be useful in patients for whom risk is unclear. The optimal threshold for determining the need for further testing has not been determined. However, NT-pro BNP 200 pg/mL or BNP 92 ng/L are reasonable cutoffs.