Preoperative Diagnostic Assessment of Patients with Cardiovascular Risk Factors Undergoing Noncardiac Surgery: A 2025 Update

Abstract

Despite medical advances and increased perioperative testing, mortality and cardiovascular complications of noncardiac surgery (NCS) have hardly declined since the early 2000s. Studies demonstrate a disproportionate overutilization of preoperative diagnostic testing with a concurrent underutilization of interventions that have been shown to meaningfully modify mortality. Consequently, there has been a paradigm shift in the approach to perioperative testing. Current thinking advocates for a more judicious and individualized approach-that is, reserving noninvasive testing for select cases at highest risk of periprocedural cardiovascular events, where it may more effectively alter management. Thus, this review provides an update of the latest evidence-based recommendations on preoperative diagnostic assessment of patients with cardiovascular risk factors undergoing NCS, proposes a framework that can be referenced when approaching such a patient in clinical practice, and highlights areas that need more data to guide decision-making in clinical practice.

Keywords: noncardiac surgery; perioperative testing; preoperative assessment; risk calculator.

Figure 1

Surgical risk stratification and associated hemodynamic shifts. TURP: transurethral resection of the prostate

Figure 2

2024 Algorithm for Perioperative Cardiac Assessment. Adapted and revised from the 2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM Guideline for Perioperative Cardiovascular Management for Noncardiac Surgery. NCS: noncardiac surgery; Hx: history; PMHx: past medical history; PSHx: past surgical history; FHx: family history; METS: Metabolic Equivalents Task Score; DASI: Duke Activity Status Index; RCRI: Revised Cardiac Risk Index; NSQIP: National Surgical Quality Improvement Program; AUB-HAS2: American University of Beirut-HAS2 Cardiovascular Risk Index