meritmedscript.blogspot.com · Clinical exam notes · October 2026

Perioperative decisions cover

Emergency proceeds.

ACS, wet failure and unstable rhythm defer elective surgery.

A test is ordered only if the result will change surgery, anaesthesia, or revascularisation.

Continue a chronic beta-blocker. Do not start one on the day.

Hold an SGLT2 inhibitor for 3–4 days.

How to use this card

Thirteen topics.

Green: proceed. Red: defer.

Within each topic the order is the consult order: emergency, unstable disease, then the modifier that changes the plan.

2026 AHA/ACC perioperative guideline, reaffirmation of 2024.

Part 1. Proceed or defer

No.	Scenario	Decision	Do not
1	Perforated viscus. Known stable CAD.	Proceed. Emergency NCS is not deferred for stratification.	Do not request a stress test first.
2	Elective hernia. Rest angina 48 h, rising troponin.	Defer. Treat ACS; revascularise if indicated before elective NCS (Class 1).	Do not stamp clearance.
3	Elective arthroplasty. New orthopnoea, oedema, NT-proBNP 4800.	Defer. Restabilise decompensated HF.	Do not send a wet patient to elective theatre.
4	Elective colectomy. Syncope, 5-second sinus pause.	Defer. Correct unstable bradyarrhythmia.	Do not treat a pause as preoperative anxiety.
5	Hip fracture, surgery in 24–48 h. RCRI 2, compensated.	Proceed after ECG, haemoglobin, creatinine.	Do not convert an urgent fracture into an elective work-up.
6	Cataract, topical anaesthesia. Prior PCI, unlimited walking.	Proceed. No ECG, stress test, echo, or biomarker panel.	Do not protocolise low-risk NCS.
7	Elective open AAA. SBP 196 or DBP 114, headache, no ischaemia.	Defer. SBP ≥180 or DBP ≥110 may justify delay of elevated-risk elective NCS (Class 2b).	Do not cancel an emergency for the same numbers.
8	Same pressure. Placental abruption, theatre now.	Proceed. Control pressure in theatre.	Do not delay life-saving surgery for a tablet.
9	SGLT2i taken this morning. Perforated ulcer.	Proceed. Flag ketoacidosis risk.	Do not delay emergency surgery for a washout.
10	Elective colectomy in 2 days. Dapagliflozin not yet held.	Postpone. Withhold SGLT2i 3–4 days (Class 1).	Do not proceed on a same-week elective list.
11	Time-sensitive cancer resection in 14 days. Stable CAD, METs >4.	Protect the oncological date. Test only if the result changes surgery.	Do not insert a non-actionable ischaemia work-up.
12	Elective hernia. Family requests a treadmill test for reassurance.	Decline. No indication.	Do not test to reduce family anxiety.
13	Remote CABG, asymptomatic, elective cholecystectomy.	Proceed. No repeat angiography.	Do not reinvestigate a complete, silent revascularisation.
14	Accelerating angina over 2 weeks. Elective AAA.	Defer. Manage as unstable CAD.	Do not book the aneurysm first.
15	Elective TURP. NSTEMI 5 days ago, not yet revascularised.	Defer. Complete ACS care (Class 1).	Do not separate the infarct from the operation by optimism.

Part 2. Risk, capacity, and frailty

No.	Scenario	Decision	Do not
16	Inguinal hernia. RCRI 0. Asymptomatic.	Proceed.	Do not calculate a score in order to clear a low-risk patient.
17	Elective colectomy. NSQIP cardiac risk 2.4%. No active symptoms.	Elevated risk (>1%). Team review. Biomarkers reasonable.	Do not equate >1% with angiography.
18	Elective open AAA. RCRI 3, DASI ≤34, no unstable features.	Poor capacity plus elevated risk. Test only if management will change (Class 2a for DASI).	Do not order a stress test by reflex.
19	Climbs two flights. No CVD. Elective cholecystectomy.	Proceed. Routine stress testing is Class 3: No benefit.	Do not convert METs >4 into a nuclear request.
20	Age 76. Elective colectomy. Slow gait, weight loss, lives alone.	Frailty assessment is reasonable at ≥65 before elevated-risk NCS (Class 2a).	Do not cancel on frailty alone.
21	Age 58, looks frail, elevated-risk NCS.	Frailty assessment is reasonable if frailty is clinically suspected.	Do not restrict the tool to age ≥65 when frailty is obvious.
22	Smoker, family history of MI. Cataract. No symptoms.	Proceed. Risk factors are not an indication for preoperative stress testing.	Do not screen the family history.
23	Prior stroke 5 months ago, recovered. Elective hernia.	Proceed. The 3-month deferral has elapsed.	Do not add a stress test for a remote stroke.
24	Ischaemic stroke 6 weeks ago. Elective prostatectomy.	Defer elective NCS ≥3 months after stroke or TIA (Class 2a).	Do not waive the interval for surgical convenience.
25	STOP-Bang 6. Elective bariatric surgery.	Questionnaire screening is reasonable (Class 2a). Use home CPAP if already treated.	Do not delay every high score for a laboratory sleep study.

Part 3. Biomarkers and postoperative injury

No.	Scenario	Decision	Do not
26	Known CVD. Elective vascular surgery. Preoperative BNP requested.	Reasonable if known CVD, age ≥65, or age ≥45 with symptoms, before elevated-risk NCS (Class 2a).	Do not treat a high BNP as an angiogram ticket.
27	Same patient. Preoperative troponin requested.	May be considered (Class 2b).	Do not cancel a stable patient for a mild isolated rise.
28	Low-risk hernia. Postoperative troponin protocol.	Not indicated.	Do not surveillance-test low-risk NCS.
29	Elevated-risk vascular patient. Day-2 troponin 180 ng/L. ECG unchanged.	MINS. Outpatient cardiovascular follow-up is reasonable (Class 2a).	Do not ignore a rise, and do not catheterise every rise.
30	ST elevation and pain 6 h after colectomy.	Postoperative STEMI: GDMT and consider ICA, balancing bleeding (Class 1).	Do not label STEMI as demand ischaemia.
31	NSTEMI pattern after NCS. Stable. Drain output settling.	Medical therapy modified for bleeding (Class 1). ICA is reasonable if selected (Class 2a).	Do not give full dual therapy into a fresh anastomosis without a surgeon.
32	Type 2 injury from bleeding and hypotension. Source controlled.	Correct the driver. MINS follow-up.	Do not stent a type 2 injury as if it were plaque rupture.
33	Day-2 MINS. Discharge prescription of aspirin proposed.	May be considered, balancing bleeding (Class 2b). Follow-up is the firmer recommendation.	Do not start DAPT into a fresh surgical field.
34	Elevated-risk patient. BNP twice normal. Surgery still appropriate.	Document the risk. Proceed if the result does not change care.	Do not reread the same BNP as a new indication for ICA.

Part 4. ECG, echo, and ischaemia testing

No.	Scenario	Decision	Do not
35	Asymptomatic. Low-risk hernia. Protocol ECG.	Routine ECG before low-risk NCS is Class 3: No benefit.	Do not collect an ECG because the form has a box.
36	Known CAD. Elective vascular bypass. New LBBB.	Further evaluation is reasonable (Class 2a).	Do not file a new bundle-branch block as a baseline.
37	Old anterior Q waves, unchanged. Elective hernia. Good capacity.	Proceed. ECG is a baseline.	Do not stress-test chronic Q waves.
38	Elective hysterectomy. New dyspnoea, S3.	LV assessment is recommended (Class 1).	Do not accept a normal ECG as a substitute.
39	Stable HFpEF, unchanged. Elective cataract.	Routine LV assessment is Class 3: No benefit.	Do not repeat echo for the theatre list.
40	Known HFrEF. Worsening dyspnoea. Elective colectomy.	Repeat LV assessment is reasonable (Class 2a).	Do not use a year-old EF.
41	Stable patient. Clearance angiogram requested before knee replacement.	Routine ICA is Class 3: No benefit.	Do not equate clearance with a catheter.
42	Poor capacity, elevated risk, elevated-risk NCS. Result would change the plan.	Stress testing may be considered (Class 2b).	Do not test if the operation will proceed regardless.
43	Low calculated risk, or METs >4, or low-risk procedure.	Routine stress testing is Class 3: No benefit.	Do not offer CCTA as a softer alternative.
44	Same selected patient. Question is high-risk anatomy.	CCTA may be considered (Class 2b).	Do not use CCTA as a screening test.
45	Low-risk patient. CCTA requested for clearance.	Routine CCTA is Class 3: No benefit.	Do not start a cascade from calcium on a non-gated CT.
46	New murmur. Elective hip replacement. Severe AS possible.	Echo before elective NCS (Class 1 if moderate or severe AS suspected).	Do not clear a new murmur on auscultation alone.
47	CPET requested to clear a cataract.	Decline.	Do not use functional testing as a ritual.
48	Abnormal BNP, stable ECG and story. Elective colectomy.	Share with anaesthesia. Optimise therapy.	Do not transfer straight to the catheter laboratory.
49	Justified stress test shows a large ischaemic burden. Elective vascular surgery.	Team discussion. Revascularise only for a spontaneous indication.	Do not stent solely to licence surgery.
50	QRS 140 ms, LBBB, elective open AAA, LVEF unknown.	ECG is reasonable. Echo, because ventricular function will change anaesthesia.	Do not book a CRT implant in order to clear surgery.

Part 5. Coronary disease

No.	Scenario	Decision	Do not
51	NSTEMI day 5. Elective TURP listed.	Defer. Revascularise if indicated before elective NCS (Class 1).	Do not split the infarct from the operation.
52	Stable angina. 70% mid-LAD. Good capacity. Elective hernia.	No revascularisation of non–left main CAD (Class 3: No benefit).	Do not stent a single vessel for perioperative cover.
53	Asymptomatic left main ≥50%, haemodynamically significant. Elective hip replacement.	Revascularisation before elective NCS is reasonable (Class 2a).	Do not proceed to major elective NCS with an unaddressed left main.
54	CCS II on GDMT. No left main. Elective hernia.	Continue medical therapy.	Do not add a preoperative stent.
55	CABG 3 years ago. Asymptomatic. Elective cholecystectomy.	Proceed.	Do not repeat angiography for the operative date.
56	Prior PCI. Stent card missing. Elective colectomy in 10 days.	Obtain date and indication before any antiplatelet is stopped.	Do not guess the interval.
57	Coronary calcium on a non-gated CT. No symptoms. Low-risk NCS.	Proceed. Address prevention separately.	Do not upgrade calcium to ICA.
58	Post-MI day 40, revascularised, stable. Time-sensitive cancer surgery.	May proceed if DAPT can be maintained.	Do not assume every post-MI patient must wait 6 months.
59	Three-vessel disease, already refused CABG, now listed for hip replacement.	Shared decision. Medical therapy. No new mandate to revascularise.	Do not reopen a declined revascularisation solely for the hip.
60	Typical angina and a new regional-wall-motion abnormality. Elective AAA.	Treat the coronary syndrome first.	Do not book the aneurysm.

Part 6. Stents and antiplatelet timing

No.	Scenario	Decision	Do not
61	DES for ACS 6 weeks ago. Cancer surgery cannot wait. DAPT interruption likely.	Avoid interruption inside 3 months. If impossible: team decision, continue aspirin.	Do not stop both agents by a surgical protocol.
62	DES for CCS 8 months ago. Elective knee. Aspirin can continue.	Proceed on aspirin. Preferred wait if DAPT must stop after DES for CCS is 6 months.	Do not stop aspirin for joint replacement.
63	BMS 3 weeks ago. Elective cholecystectomy. DAPT would stop.	Delay to ≥30 days.	Do not apply the DES clock to a bare-metal stent.
64	POBA, no stent, 10 days ago. Elective hernia.	Delay elective NCS to ≥14 days.	Do not treat balloon angioplasty as stent-free permission.
65	DES 14 months ago. Aspirin only. Elective hernia.	Proceed.	Do not reapply a 12-month rule after the window.
66	DES for ACS 5 months ago. Elective arthroplasty. Surgeon can operate on aspirin.	Prefer 12 months if DAPT must stop after an ACS stent. Aspirin continuation: shared decision.	Do not stop the P2Y12 inhibitor without a date.
67	DES 3 weeks ago. Cataract. Ophthalmology wants both agents stopped.	Do not stop DAPT for cataract.	Do not equate eye surgery with major bleeding.
68	Dental extraction. DES 4 months ago for CCS.	Continue aspirin. Cardiology review before stopping a P2Y12 inhibitor inside 6 months.	Do not use a 5-day DAPT hold for a dental case.
69	Very high thrombotic risk, <6 months after DES, surgery requires interruption.	Bridging is not routine. It may be considered only here, after team review.	Do not bridge every stent.
70	CCS, no PCI. Elective hernia. Aspirin not previously indicated.	Do not start aspirin for the operation.	Do not copy secondary-prevention aspirin into primary prevention.
71	DES 7 months after ACS. Urgent fractured neck of femur.	Operate. Maintain aspirin. Accept residual stent risk.	Do not defer a fracture to complete 12 months.
72	Stent card: DES for CCS 9 months ago. Aspirin only. Inguinal hernia.	Proceed.	Do not reconsult if the interval and the drug plan are already documented.
73	Unknown stent type, 5 weeks ago. Elective bowel surgery.	Treat as a short-interval stent. Defer if elective.	Do not assume it was a balloon.
74	DAPT, surgery in a body cavity, surgeon requests 7 days off both agents.	Counter-propose aspirin continuation and the shortest possible P2Y12 hold.	Do not sign a blanket cessation.
75	After haemostasis, day 2, stent 4 months ago, P2Y12 was held.	Restart the P2Y12 inhibitor as soon as bleeding allows.	Do not leave the second agent off until clinic.

Part 7. Medicines

No.	Scenario	Decision	Do not
76	Chronic metoprolol. Morning of leg bypass.	Continue (Class 1).	Do not omit a chronic beta-blocker.
77	Beta-blocker-naive. Start at 06:00 on the day of surgery.	Class 3: Harm.	Do not initiate on the day of surgery.
78	New Class I indication. Elective NCS in 10 days.	Initiation ≥7 days before may be considered (Class 2b).	Do not start the night before.
79	Established atorvastatin. Elective AAA.	Continue (Class 1).	Do not hold a statin for theatre.
80	Statin-naive. Prior MI. Elective vascular surgery.	Initiate if a long-term indication exists, and continue (Class 1).	Do not expect a short-term MACE reduction.
81	Request to start clonidine to reduce cardiac risk.	Class 3: No benefit.	Do not initiate clonidine.
82	Lisinopril for hypertension only. BP 128/76. Elective open AAA.	Omission about 24 h before may limit hypotension (Class 2b).	Do not stop an ACE inhibitor in HFrEF by the same reflex.
83	Sacubitril/valsartan for compensated HFrEF. Also on empagliflozin.	Continue GDMT except the SGLT2i (Class 2a). Hold SGLT2i 3–4 days.	Do not stop the ARNI because the SGLT2i is held.
84	Weekly semaglutide yesterday. Elective laparoscopic cholecystectomy.	Hold GLP-1 receptor agonist before elective NCS.	Do not apply the same delay to emergency surgery.
85	Metformin. Day-case hernia. eGFR normal.	Continuation is reasonable.	Do not confuse metformin with an SGLT2i.
86	HbA1c not checked for 5 months. Elective colectomy. Diabetes.	Preoperative HbA1c is reasonable if none within 3 months (Class 2a).	Do not cancel for a missing HbA1c alone.
87	Amlodipine for hypertension. Elective hernia.	Continue. Anticipate vasodilation.	Do not stop a dihydropyridine by habit.
88	ACE inhibitor plus ARB from two clinics.	Reconcile to one RAASi.	Do not continue duplicate blockade into theatre.
89	Non-dihydropyridine calcium blocker. Resting rate 48. Elective NCS.	Continue if the rate is chronic and stable. Flag anaesthesia.	Do not add a beta-blocker on the day.
90	Nitrate used for effort angina. Elective hernia. Stable.	Continue. Not a revascularisation indication.	Do not read nitrate use as unstable CAD.

Part 8. Valvular disease

No.	Scenario	Decision	Do not
91	Severe symptomatic AS. Elective hernia under general anaesthesia.	AVR evaluation before elective NCS (Class 1).	Do not clear symptomatic severe AS.
92	Asymptomatic severe AS. Normal LVEF. Topical cataract.	Low-risk NCS may proceed (Class 2a).	Do not extend that permission to open abdominal surgery.
93	Severe MS. Dyspnoea. Elective hysterectomy.	Mitral intervention before elective NCS (Class 1).	Do not rely on rate control as a substitute if intervention is feasible.
94	Asymptomatic severe MR. Normal LV. PASP <50. Elective hernia.	NCS is reasonable (Class 2a).	Do not ignore a spontaneous repair indication before elevated-risk NCS.
95	Severe AR. Normal LV. Elective cholecystectomy.	Reasonable to proceed (Class 2a).	Do not send severe AR with a spontaneous indication into elevated-risk NCS untreated.
96	Successful TAVI 6 weeks ago. Normal function. Elective hernia.	Early NCS is reasonable (Class 2a).	Do not impose a 6-month wait.
97	Successful TEER. Residual MR mild. Elective hernia.	Early NCS is reasonable (Class 2a).	Do not repeat clipping for the operative date.
98	Moderate AS, mean gradient 25 mm Hg. No symptoms. Elective colectomy.	Confirm on echo. Arterial line. No AVR for this operation alone.	Do not upgrade moderate AS to a valve replacement.
99	Prosthetic AVR. Fever. New murmur. Elective knee replacement.	Defer. Exclude prosthetic endocarditis.	Do not give surgical prophylaxis and proceed.
100	Mechanical AVR. Therapeutic INR. Cataract.	Most cataract surgery proceeds on warfarin.	Do not stop a mechanical-valve anticoagulant for eye surgery.
101	Mechanical mitral valve. Warfarin. Elective bowel resection.	Heparin bridge is reasonable (Class 2a).	Do not simply omit warfarin.
102	Bioprosthetic AVR. 2 years. No dysfunction. Elective hernia.	Proceed. Standard prophylaxis only.	Do not bridge a tissue valve.
103	Suspected severe AS. No echo for 3 years. Elective colectomy.	Echo first (Class 1 if moderate or severe disease is suspected).	Do not accept an old gradient.
104	Mild AS. Mean gradient 16. Elective AAA.	Proceed with arterial monitoring. No valve intervention.	Do not delay aneurysm repair for mild AS.
105	Mitral valve prolapse. No regurgitation. Emergency laparotomy.	Proceed.	Do not defer emergency surgery for a click.

Part 9. Myocardium, pulmonary hypertension, congenital disease

No.	Scenario	Decision	Do not
106	HCM. Resting LVOT gradient 50 mm Hg. Laparoscopic cholecystectomy.	Continue beta-blocker. Hypovolaemia, tachycardia and inotropes are Class 3: Harm.	Do not use inodilators as first-line for hypotension.
107	PAH on targeted therapy. Elective hip replacement.	Continue PAH therapy (Class 1).	Do not hold sildenafil or a prostacyclin for theatre.
108	Severe PH. Elevated-risk NCS.	PH-centre referral and invasive monitoring are reasonable (Class 2a).	Do not use a routine PAC in unselected NCS (Class 3: No benefit).
109	Pre-capillary PH. Inhaled vasodilator proposed.	May be considered (Class 2b).	Do not substitute it for chronic PAH therapy.
110	Unrepaired shunt or systemic right ventricle. Elective colectomy.	ACHD consultation before intermediate- or elevated-risk lesions (Class 1).	Do not manage this as ordinary HFpEF.
111	Repaired ASD. No residual. Normal function. Elective hernia.	Proceed. Check endocarditis prophylaxis.	Do not transfer every repaired simple lesion.
112	LVAD. Cholecystectomy booked at a non-implanting hospital.	Coordinate with the LVAD team (Class 1).	Do not proceed off-site.
113	Fontan circulation. Elective laparoscopy.	ACHD and anaesthesia plan. Defend preload.	Do not manage abdominal insufflation casually.

Part 10. Pacemakers and defibrillators

No.	Scenario	Decision	Do not
114	Pacemaker-dependent. Colectomy. Monopolar diathermy above umbilicus.	EMI plan (Class 1). Reprogram or magnet. Restore settings before leaving recovery.	Do not leave a magnet on overnight.
115	Secondary-prevention ICD. Shoulder surgery. Monopolar diathermy.	Suspend tachy-therapies. Restore before ward transfer.	Do not use a magnet as the overnight plan.
116	MRI-conditional pacemaker. Surgery below the umbilicus. Bipolar diathermy.	Document the device. Low EMI risk. Still name a responsible operator.	Do not skip the device check because the site is distant.
117	ICD therapies left off after surgery.	Restore therapies before transfer.	Do not discharge with therapies suspended.
118	CRT-D. Elective hip. Diathermy.	Same EMI plan as an ICD, plus the pacing indication.	Do not turn CRT off without a restart time.
119	Leadless pacemaker. Hip surgery.	EMI risk is low. Confirm if monopolar current is near the device.	Do not apply a transvenous magnet protocol blindly.
120	Subcutaneous ICD. Abdominal surgery.	Write an EMI plan. Magnet behaviour differs from a transvenous ICD.	Do not assume a transvenous magnet works.

Part 11. Atrial fibrillation and anticoagulation

No.	Scenario	Decision	Do not
121	Day-1 new AF, 140/min. Stable pressure. No ischaemia.	Treat triggers. Rate control is reasonable (Class 2a).	Do not cardiovert a stable postoperative patient as the first act.
122	New perioperative AF, now sinus. Discharge tomorrow.	Outpatient thromboembolic assessment and surveillance are recommended (Class 1).	Do not call it a reversible electrolyte problem and forget it.
123	Beta-blocker requested solely to prevent postoperative AF.	Routine prophylaxis is not recommended.	Do not start a beta-blocker for this indication on the day.
124	Chronic AF. Apixaban. eGFR normal. Elective knee replacement.	Time-based interruption, typically 48 h. No heparin bridge.	Do not bridge a DOAC.
125	DOAC. eGFR 25. Major abdominal surgery.	Lengthen the interruption. Check the agent-specific interval.	Do not use the 24-hour low-bleeding rule.
126	DOAC. Low-bleeding dental extraction.	Morning omission is often enough.	Do not apply a 72-hour surgical hold.
127	CHA2DS2-VASc 4. Day 2. Haemostasis secure. AF persists.	Start anticoagulation (Class 2a).	Do not defer a thinner until the clinic.
128	Mechanical mitral valve. Plan to simply stop warfarin for bowel resection.	Bridge with heparin (Class 2a).	Do not leave a mechanical mitral valve uncovered.
129	AF. CHA2DS2-VASc 1. Cataract.	Proceed. Anticoagulation usually continues.	Do not stop a thinner for eye surgery by protocol.
130	Stable rate-controlled AF. Elective hernia. Anticoagulant plan written.	Proceed. AF alone is not a deferral.	Do not cardiovert before a low-risk operation.

Part 12. Theatre, anaesthesia, and blood pressure

No.	Scenario	Decision	Do not
131	Intraoperative MAP 52 mm Hg for 10 min. No bleeding.	Treat. Maintain MAP ≥60–65 or SBP ≥90 (Class 1).	Do not accept a low pressure as anaesthetic normal.
132	Postoperative hypotension. MAP <60–65 or SBP <90.	Treat (Class 1). Restart antihypertensives only when euvolaemic.	Do not restart an ACE inhibitor into ongoing hypotension.
133	Unexplained intraoperative collapse. Echo skill available.	Emergency TEE or focused ultrasound is reasonable (Class 2a).	Do not use routine TEE in an unselected stable patient (Class 3).
134	Routine PAC requested for a hip replacement.	Class 3: No benefit.	Do not float a catheter for comfort.
135	Elective liver transplant. Routine ICA proposed for every candidate.	Targeted CAD assessment. No outcome gain from unselected invasive screening.	Do not catheterise every transplant candidate.
136	Elective kidney transplant. ISCHEMIA-CKD logic raised.	Invasive strategy is not superior to medical therapy in advanced CKD without a spontaneous indication.	Do not promise a preoperative stent will fix transplant risk.
137	BMI 42. Established CVD. Bariatric surgery proposed.	Preoperative assessment still follows the same ladder. Hold SGLT2i and GLP-1 as indicated.	Do not skip the drug holds.
138	Obesity alone. Low-risk NCS. No symptoms.	Proceed. Weight is not an indication for stress testing.	Do not order a clearance echo for BMI.
139	Anaemia, haemoglobin 8.2 g/dL. Elective AAA. Known CAD. Iron deficient.	Iron repletion is reasonable (Class 2a).	Do not delay emergency surgery for iron.
140	Major orthopaedic bleeding expected. Tranexamic acid proposed.	Reasonable to reduce blood loss (Class 2a).	Do not withhold it solely because of stable CAD.
141	Neuraxial versus general anaesthesia. No drug contraindication.	Either is reasonable. No cardiac-event difference (Class 2a).	Do not insist on general anaesthesia for cardiac safety.
142	Major open abdomen. Epidural proposed.	Reasonable to reduce cardiac events (Class 2a).	Do not place an epidural on uninterrupted dual therapy or a therapeutic DOAC.
143	Volatile versus total intravenous anaesthesia.	Either is reasonable (Class 2a).	Do not choose the agent as cardiovascular therapy.
144	Normothermia not planned for a long case.	Maintain normothermia (Class 2a).	Do not ignore hypothermia as a cardiac stress.
145	Preemptive temporary mechanical support proposed for silent three-vessel disease.	May be considered only for acute severe instability (Class 2b).	Do not insert a pump to avoid a medical decision.

Part 13. How the consult is written

No.	Scenario	Decision	Do not
146	Low-value CCTA, ECG and biomarkers requested together for cataract.	Decline the panel.	Do not order a bundle because each item looks small.
147	Patient declines a justified left-main revascularisation and wants the hip.	Record capacity, the quoted risk, and the declined alternative.	Do not write cleared.
148	Note requested: cardiac clearance given.	Rewrite as risk estimate, active problems, and drug plan.	Do not sign clearance.
149	Trauma laparotomy. Prior echo showed mitral-valve prolapse only.	Proceed. Echo only if the valve lesion may change immediate management.	Do not defer trauma surgery for a click.
150	Evening before the list. Unresolved: stent date, SGLT2i, pacemaker, new murmur.	Settle the four items or defer elective NCS.	Do not add a fifth test.

Sources

2026 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM Guideline for Perioperative Cardiovascular Management for Noncardiac Surgery.

J Am Coll Cardiol. 2026;88:1543–1643.

Surveillance through March 2026 changed no recommendation.