Preoperative cardiac risk assessment for noncardiac surgery.

Patients presenting for noncardiac surgery should receive careful preoperative cardiac risk stratification. This has implications not only for the perioperative period, but also for long-term survival. After an initial clinical evaluation, certain patients will be referred for noninvasive testing. Those without significant inducible ischemia at a high workload have a low risk for perioperative cardiac complications. Patients who are unable to exercise adequately may require alternative forms of testing, of which dipyridamole thallium scintigraphy is the most thoroughly studied and validated option. Patients with either high-risk clinical profiles or significant thallium redistribution merit consideration for preoperative coronary angiography. Treatment options for high-risk patients include: (1) Proceeding with surgery as planned along with aggressive perioperative monitoring and anti-ischemic therapy, (2) coronary angiography with subsequent myocardial revascularization as appropriate before elective surgery, (3) selecting an alternative, lower risk surgical approach, and (4) cancellation of surgery in lieu of a trial of conservative therapy.