Romero and de Virgilio developed an algorithm for evaluating the cardiac risk for a patient having noncardiac surgery. This can help determine the optimum management strategy prior to surgery. The authors are from the Harbor UCLA Medical Center in Torrance, California.


Initial Evaluation


Need for surgery:

(1) emergency

(2) urgent

(3) nonurgent


Major clinical predictors for increased perioperative cardiac risk:

(1) recent myocardial infarction (> 7 days but <= 1 month)

(2) unstable or severe angina (Canadian Class III or IV)

(3) decompensated congestive heart failure

(4) significant dysrhythmias (high-grade AV block, symptomatic dysrhythmias, or supraventricular tachycardia with uncontrolled ventricular rate)

(5) severe valvular disease


Cardiac risk factors (Eagle et al):

(1) age > 70 years

(2) history of angina

(3) prior myocardial infarction history or the presence of Q waves on ECG

(4) diabetes mellitus

(5) history of ventricular ectopy requiring therapy

(6) history of congestive heart failure


Level of cardiac risk associated with the procedure (see 06.03.04):

(1) low

(2) moderate

(3) high




Sequential rules for a person being evaluated for noncardiac surgery:

(1) If the person requires emergent surgery, then take to the operating room immediately.

(2) If the person has a major clinical predictor for increased perioperative cardiac risk, then perform a coronary angiogram prior to surgery.

(3) If the person has had a coronary revascularization procedure within the past 5 years and does not have new cardiac symptoms, then the person can proceed to surgery.

(4) If the person has (a) had a coronary revascularization procedure within the past 5 years and had onset of new cardiac symptoms, (b) had a coronary revascularization procedure 5 or more years ago, or (c) not had a cardiac revascularization procedure, then (a) determine the number of cardiac risk factors and (b) the risk of the procedure.


Number of Risk Factors

Risk Level for Surgery




proceed to OR



proceed to OR with beta-blocker

>= 2

low or moderate risk

proceed to OR with beta-blocker

>= 2

high risk and urgent surgery

either proceed to OR with beta blocker or modify operation

>= 2

high risk and nonurgent surgery

perform a dobutamine stress echo-cardiogram; if negative proceed to the OR with beta blocker; if positive, see below


If high risk surgery with >= 2 risk factors and the dobutamine stress echocardiogram is positive, then the options are:

(1) cancel surgery

(2) modify the operation t a less risk procedure

(3) proceed to the OR with a beta blocker

(4) perform a coronary angiogram

To read more or access our algorithms and calculators, please log in or register.