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Pre-op Testing Guide

Pre-op Testing Guidelines

A guideline is an evidence-based recommendation to assist clinical decision-making — not a rule, but a framework that supports professional judgement.

Based on NICE NG45, 2022 ESC/ESAIC & 2024 AHA/ACC Guidelines

Note — Age & Preoperative Testing:
  • NICE NG45: Age alone does not trigger preoperative testing.
  • ESC 2022: Age ≥65 is an independent cardiovascular risk factor that qualifies patients for biomarker testing (troponin — Class I, BNP — Class IIa) before intermediate or high-risk surgery, and lowers the threshold for cardiac investigations, particularly when combined with limited functional capacity.
  • AHA/ACC 2024: Age is incorporated into the NSQIP surgical risk calculator rather than listed as a standalone trigger (RCRI does not include age).
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Step 1 — Classify the Surgery

Minor
ESC/AHA: Low (<1% MACE)
  • Skin lesion excision
  • Abscess drainage
  • Hernia (local/day case)
  • All endoscopy
  • Dental, ophthalmological
  • Minor orthopaedic
  • Minor uro/gynae, breast
  • Thyroid
  • Plastic / reconstructive
  • VATS minor lung
Intermediate
ESC/AHA: 1–5% MACE
  • Cholecystectomy
  • Hiatal hernia repair
  • Splenectomy
  • Inguinal hernia (GA)
  • Tonsillectomy
  • Varicose veins
  • Carotid endarterectomy
  • Peripheral angioplasty
  • Major ortho (hip/spine)
  • Major uro / renal transplant
  • Major gynae
  • Major neuro
  • Head & neck
Major / Complex
ESC/AHA: High (>5% MACE)
  • Joint replacement
  • Colectomy / bowel
  • Hysterectomy
  • Aortic / major vascular
  • Limb revasc / amputation
  • Oesophagectomy
  • Pneumonectomy
  • Duodeno-pancreatic
  • Liver / pancreatic resection
  • Transplant (liver/lung)
  • Total cystectomy
  • Perforated bowel

Step 2 — ASA Physical Status

ASA 1
Healthy — no systemic disease
  • No comorbidities
  • Non-smoker, BMI <30
ASA 2
Mild disease — no functional limit
  • Current smoker
  • Social drinker
  • Pregnancy
  • Obesity (BMI 30–40)
  • Well-controlled DM (NIDDM)
  • Well-controlled HTN
  • Mild asthma / lung disease
  • Controlled epilepsy
  • Controlled dysrhythmias
  • Asymptomatic congenital cardiac
  • Well-controlled GORD
ASA 3
Severe disease — functional limit
  • Poorly controlled DM/HTN
  • COPD
  • Morbid obesity (BMI >40)
  • Hepatitis / alcohol dependence
  • Pacemaker / ICD
  • Reduced ejection fraction
  • Hx MI/stents/CABG (>3mo)
  • Hx CVA/TIA (>3mo)
  • Dialysis
ASA 4 — Constant threat to life: Recent (<3mo) MI/CVA/stents | Ongoing ischaemia | Severe valve disease | Severely reduced EF | Sepsis

Step 3 — Which Tests to Order (NICE NG45)

Yes = offer test  |  Consider = if clinically indicated  |  — = not routinely

Minor Surgery

TestASA 1ASA 2ASA 3–4
FBC———
Kidney——Consider
Haemostasis———
ECG——Consider*
Lung Fn / ABG———
Troponin (ESC/AHA)———
BNP (ESC/AHA)———

Intermediate Surgery

TestASA 1ASA 2ASA 3–4
FBC——Consider
Kidney—ConsiderYes
Haemostasis——Consider
ECG—Consider*Yes
Lung Fn / ABG——Consider
Troponin (ESC/AHA)—ConsiderYes
BNP (ESC/AHA)—ConsiderYes

Major / Complex Surgery

TestASA 1ASA 2ASA 3–4
FBCYesYesYes
KidneyConsiderYesYes
Haemostasis——Consider
ECGConsider* (>65)YesYes
Lung Fn / ABG——Consider
Troponin (ESC/AHA)Consider (>65)YesYes
BNP (ESC/AHA)Consider (>65)YesYes

* No recent ECG in hospital records (last 6–12 months) → ECG Yes.

Step 4 — Cardiac Investigations (AHA/ACC 2024)

Stepwise Cardiac Assessment

  1. Surgery urgency? Emergency (<2hr), Urgent (2–24hr), Time-sensitive (<3mo), Elective
  2. Unstable cardiac condition? ACS, decompensated HF, unstable arrhythmia → defer elective surgery
  3. Estimate MACE risk: Low (<1%) → proceed. Elevated (≥1%) → continue
    ACS NSQIP Surgical Risk Calculator — patient-specific risk (includes age, comorbidities, procedure)
    RCRI (Lee's Index) — 6-factor bedside estimate (does not include age)
  4. Risk modifiers? Severe valvular disease, pulmonary HTN, prior PCI/CABG, recent stroke, cardiac devices, frailty
  5. Functional capacity: Can they climb 2 flights of stairs? (≥4 METs) → low risk, proceed
  6. Poor capacity + elevated risk → biomarkers, then stress test if it changes management
Troponin
  • Pre-op: Consider if elevated risk + poor exercise capacity
  • Post-op: Consider at 24 + 48hr in high-risk patients
BNP / NT-proBNP
  • Consider if elevated risk + poor exercise capacity
  • Normal (BNP <92, NT-proBNP <300) → no further cardiac tests
Echocardiography
  • New dyspnoea / worsening symptoms
  • Suspected mod-severe valvular disease
  • Not routine if stable + echo <1yr
Stress Testing
  • Only if result changes management
  • Not indicated if low risk or ≥4 METs
  • CT coronary angio is an alternative
Functional Capacity — Quick Guide
≥4 METs (good) → Proceed
  • Climb 2 flights of stairs
  • Walk up a hill
  • Walk at 6 km/h on flat
  • Heavy housework
<4 METs (poor) → Assess further
  • Cannot climb 1 flight
  • Short distances only on flat
  • Light housework only
  • → Biomarkers → stress test

Step 5 — Other Tests

HbA1c

No diabetes: not routine. Known diabetes: offer if not tested in 3 months.

Pregnancy Test

Ask all women of childbearing potential on day of surgery. Test with consent if uncertain.

Anticoagulants

Individualised plan in line with local guidance if modification needed.

Stent Timing

DES for ACS: delay elective surgery 12 months. Continue aspirin where possible.

Do NOT Routinely Order

  • Chest X-ray — not recommended as routine
  • Sickle cell testing — ask about history only
  • Urine dipstick — not routine (culture only if UTI affects decision)
  • Resting echocardiography — not routine (see cardiac section for exceptions)
  • Haemostasis / clotting — not routine unless liver disease or anticoagulants

Key Principles

  • Only test if the result will change management
  • Always consider the patient's current medications
  • Do not repeat recent tests unless clinical picture has changed
  • Adults (>16 years), elective surgery only
  • Does not cover: pregnant women, cardiothoracic surgery, or neurosurgery
References:
1. NICE Guideline NG45: Routine Preoperative Tests for Elective Surgery (April 2016)
2. 2022 ESC/ESAIC Guidelines on CV Assessment of Patients Undergoing Non-Cardiac Surgery. Eur Heart J. 2022;43(39):3826–3924
3. 2024 AHA/ACC Guideline for Perioperative CV Management for Noncardiac Surgery. Circulation. 2024;150(24):e456–e528
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