Perioperative Risk Stratification

Risk Assessment Framework

The American College of Cardiology and Circulation recommend a perioperative risk stratification approach that includes validated risk prediction tools, assessment of functional capacity, and evaluation of surgery-specific risk factors to guide clinical decision-making and optimize patient outcomes 1, 2
Classify the surgical procedure by risk level (low, intermediate, or high-risk) based on the invasiveness and potential for hemodynamic stress, with emergency procedures carrying 2-5 times higher risk than elective surgeries 3
The Revised Cardiac Risk Index (RCRI) is a simple, validated tool that assigns 1 point for each of 6 predictors to assess risk of major cardiac complications, with the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) perioperative MI and cardiac arrest (MICA) risk calculator providing superior predictive discrimination 1, 4
Functional capacity is a critical predictor of perioperative adverse cardiovascular events, with the Duke Activity Status Index (DASI) being a semi-quantitative tool that assesses ability to perform 12 daily activities, and poor functional capacity (inability to achieve 4 METs) indicating increased risk 4, 5

Age-related physiological decline, multi-morbidity, and frailty are independently associated with increased perioperative risk, with key cardiovascular risk factors including unstable coronary syndromes, decompensated heart failure, significant arrhythmias, and severe valvular disease 6, 7
Additional risk factors include history of heart disease, compensated heart failure, cerebrovascular disease, diabetes mellitus, renal insufficiency, and B-type natriuretic peptide level before surgery being an additional risk stratification factor 7

The American College of Surgeons recommends screening for modifiable risk factors including smoking, alcohol usage, undiagnosed hypertension, diabetes, anemia, and nutritional status, with smoking cessation at least 4 weeks before surgery and alcohol abstinence for 4 weeks prior to surgery being recommended 8
Consider perioperative statin therapy, which may confer benefits through pleiotropic anti-inflammatory effects, according to the Journal of the American College of Cardiology 2

The American Geriatrics Society recommends performing multidisciplinary assessment with early involvement of geriatricians and anesthesiologists for elderly patients, evaluating minimum criteria for adequate pre-operative geriatric assessment specific to anesthesia, and considering age-related physiological changes that may affect perioperative risk 6
The American College of Chest Physicians recommends stratifying patients for periprocedural thromboembolism risk and assessing surgery/procedure-related bleeding risk to develop an individualized plan for perioperative antithrombotic management 9
Patients with coronary artery disease (CAD) have increased risk of perioperative major adverse cardiac events (MACE), with consideration of myocardial injury after noncardiac surgery (MINS) surveillance in high-risk patients being recommended by the Journal of the American College of Cardiology 2

Risk scores have poorer discrimination in patients undergoing vascular surgery, likely due to underestimation of MI risk, according to Circulation 1
Adherence to perioperative management guidelines is often poor, representing a clear opportunity for improving quality of care, as stated by the European Heart Journal 10
Avoid relying solely on age as a risk factor; greater risks are associated with urgency and significant cardiac, pulmonary, and renal disease, as recommended by the European Heart Journal 10

The American College of Cardiology recommends considering patients with congenital heart disease, assessing complexity and severity of the disease, with single-ventricle patients and those with unrepaired or palliated cyanotic CHD at elevated risk 11, 12
The American Society of Anesthesiologists (ASA) suggests evaluating for obstructive sleep apnea using a validated screening tool, as OSA increases perioperative risk of complications 13, 14
The British Journal of Anaesthesia guidelines recommend assessing for risk of postoperative delirium, particularly in elderly patients, with key risk factors including age, ASA physical status >2, and Charlson Comorbidity Index ≥2 15, 16

The American College of Chest Physicians (ACCP) estimates the risk for arterial thromboembolism (ATE) for patients with atrial fibrillation or mechanical heart valves and risk for recurrent VTE for patients with history of VTE 17, 18
The ACCP classifies patients according to estimated risk for ATE (high risk: >10%/year; intermediate risk: 4%-10%/year; low risk: <4%/year) and estimated risk for VTE (high risk: >10%/month; intermediate risk: 4%-10%/month; low risk: <2%/month) 17, 18

The American Heart Association (AHA) categorizes surgical procedures as low risk (<1% risk of MACE) or elevated risk (≥1% risk of MACE) based on combined surgical and patient characteristics 19
The AHA defines surgical timing as emergency (immediate threat to life or limb, <2h), urgent (threat to life or limb, ≥2 to <24h), time-sensitive (can be delayed up to 3 months), or elective (can be delayed for complete evaluation) 19
The American College of Cardiology recommends that for patients with low risk of perioperative MACE, further cardiac testing is not recommended before the planned operation 11