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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.
NICE NG45 | ESC/ESAIC 2022 | AHA/ACC 2024
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).
Step 1 — What Grade of Surgery?
Minor
Low risk (<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
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 / neuro Head & neck
Major / Complex
High risk (>5% MACE)
Joint replacement Colectomy / bowel Hysterectomy Aortic / major vascular Limb revasc / amputation Oesophagectomy Pneumonectomy Duodeno-pancreatic Liver resection / transplant Total cystectomy Perforated bowel
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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 / 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
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Step 3 — Which Tests to Order (NICE NG45)
Yes = offer | Consider = if indicated | — = not routinely
Minor Surgery
Test ASA 1 ASA 2 ASA 3–4
FBC — — — Kidney — — Consider Haemostasis — — — ECG — — Consider* Lung Fn — — — Troponin (ESC/AHA) — — — BNP (ESC/AHA) — — —
Intermediate Surgery
Test ASA 1 ASA 2 ASA 3–4
FBC — — Consider Kidney — Consider Yes Haemostasis — — Consider ECG — Consider* Yes Lung Fn — — Consider Troponin (ESC/AHA) — Consider Yes BNP (ESC/AHA) — Consider Yes
Major / Complex Surgery
Test ASA 1 ASA 2 ASA 3–4
FBC Yes Yes Yes Kidney Consider Yes Yes Haemostasis — — Consider ECG Consider* (>65) Yes Yes Lung Fn — — Consider Troponin (ESC/AHA) Consider (>65) Yes Yes BNP (ESC/AHA) Consider (>65) Yes Yes
* No recent ECG in hospital records (last 6–12 months) → ECG Yes.
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Step 4 — Cardiac Investigations (AHA/ACC 2024)
Stepwise Cardiac Assessment
Surgery urgency? Emergency (<2hr), Urgent (2–24hr), Time-sensitive (<3mo), ElectiveUnstable cardiac condition? ACS, decompensated HF, unstable arrhythmia → defer electiveEstimate MACE risk: Low (<1%) → proceed. Elevated (≥1%) → continue
Risk modifiers? Severe valvular disease, pulmonary HTN, prior PCI/CABG, recent stroke, frailtyFunctional capacity: Climb 2 flights of stairs? (≥4 METs) → low risk, proceedPoor capacity + elevated risk → biomarkers, then stress test if it changes management
Troponin
Pre-op: Consider if elevated risk + poor exercise capacityPost-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
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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.
Anticoagulants Individualised plan in line with local guidance.
Stent Timing DES for ACS: delay elective surgery 12 months . Continue aspirin where possible.
Do NOT Routinely Order
Chest X-ray — not recommended as routineSickle cell testing — ask about history onlyUrine dipstick — not routineResting echo — not routine (see cardiac section)Haemostasis — not routine unless liver disease or anticoagulants
Key Principles
Only test if it will change management Consider current medications Don't repeat recent tests unless clinical picture changed Adults (>16 yrs), elective surgery only Does not cover: pregnant women, cardiothoracic, or neurosurgery