Preoperative Risk Stratification

1Procedure

Planned surgery / procedure
Used in copied assessment
Age
Used for pulmonary risk and postop surveillance
Timing
Procedure risk
Select a procedure risk.

2Active Cardiac Conditions

Acute coronary syndrome / active ischemia
Decompensated heart failure
New/worsening congestion, hypoperfusion, or unstable symptoms
Unstable significant arrhythmia
HD instability, uncontrolled rapid HR, high-grade conduction disease, etc.

3RCRI & Risk Modifiers

RCRI
RCRI high-risk procedure
Intraperitoneal, intrathoracic, or suprainguinal vascular surgery
Ischemic heart disease
History of heart failure
History of stroke / TIA
Diabetes requiring insulin
Creatinine ≥2.0 mg/dL
RCRI
0
Low calculated risk
AHA/ACC calculated-risk
<1%
RCRI >1 traditionally identifies elevated calculated risk
Diabetes / glycemic risk
Hemoglobin A1c
Elective preop goal <8% within 3 months · periop glucose goal 100–180 mg/dL
Risk modifiers
Severe valvular heart disease
Severe pulmonary hypertension
Elevated-risk congenital heart disease
Prior PCI / CABG
Recent stroke
Pacemaker / ICD
Frailty
Needs help with IADLs/ADLs, slow mobility, weakness, or recurrent falls
Other clinically relevant risk modifier
Optional · does not change RCRI or calculated cardiac risk

4Functional Capacity

Estimated METs
Unknown: Treat as poor/indeterminate functional capacity for the decision pathway.

5Optional Cardiac Testing

Complete the cardiac assessment.
Would additional testing change the decision to operate or perioperative management?
Optional preoperative biomarkers
Most useful in selected elevated-risk patients. Enter if obtained.
NT-proBNP
Abnormal ≥300 ng/L
High-sensitivity troponin
Reference 3–35 · abnormal >35
No biomarker result entered.

6Pulmonary Risk

Optional

Pulmonary risk factors
COPD
Asthma
OSA / OHS
Interstitial lung disease
Home oxygen
Current smoker
Preop SpO₂
Room air when possible
Respiratory infection within 1 month
Hemoglobin
≤10 g/dL adds points
Surgical incision
Expected duration
0
ARISCAT low risk

7Liver Risk

Optional

Liver disease
Cirrhosis severity
Ascites
Hepatic encephalopathy
Portal hypertension / prior variceal bleeding
MELD 3.0
Sex used for adult MELD
Bilirubin
mg/dL
INR
Creatinine
mg/dL
Sodium
mEq/L
Albumin
g/dL
Dialysis ≥2 times or ≥24 h CVVHD in past week
—
Enter labs to calculate adult MELD 3.0
MELD 3.0 reflects liver disease severity, not procedure-specific surgical mortality. Consider VOCAL-Penn for a surgery-specific cirrhosis estimate when needed.
No major liver-specific risk identified.

8Medication Management

Optional

Medication guidance: default elective noncardiac-surgery recommendations. Procedure-specific, anesthesia, surgeon, and prescribing-team instructions supersede these defaults.
Cardiac / blood pressure
Beta blocker
Chronic therapy
Clonidine / central α2-agonist
Abrupt withdrawal can cause rebound hypertension
CCB / nitrate / antiarrhythmic
Statin
ACEi / ARB / ARNI
Primary indication
Loop / thiazide diuretic
Mineralocorticoid receptor antagonist
Spironolactone / eplerenone
Digoxin
PAH-targeted therapy
PDE5i / endothelin antagonist / prostacyclin pathway therapy
Antithrombotics
Procedure bleeding risk
Used only for antithrombotic recommendations
Minimal: minor dental/skin/cataract, many diagnostic endoscopic procedures ± mucosal biopsy · Low/moderate: most standard operations · High: major cancer, joint replacement, major organ surgery
Aspirin
Indication
P2Y12 inhibitor
Drug
PCI timing
If prescribed for a coronary stent
DOAC
DOAC
Creatinine clearance
Most important for dabigatran
Warfarin
Thromboembolic risk if interrupted
High-risk examples: mechanical mitral valve, recent stroke/systemic embolism, recent LV thrombus, or other very high-risk indication
LMWH / enoxaparin
Dose
Diabetes
SGLT2 inhibitor
Drug
Metformin
Sulfonylurea / meglitinide
Other oral diabetes agent
DPP-4 inhibitor, TZD, α-glucosidase inhibitor, etc.
GLP-1 / dual GIP-GLP-1 agonist
Aspiration-risk features
Dose-escalation phase
Significant GI symptoms
Nausea/vomiting, abdominal pain/distension, poor PO tolerance
High dose
Other delayed gastric emptying risk
Gastroparesis, Parkinson disease, etc.
Long-acting basal insulin
Glargine / detemir / degludec
NPH insulin
Mealtime insulin
Insulin pump
Steroid / pulmonary
Chronic systemic steroids
HPA-axis suppression risk
At-risk: generally >3–4 weeks of systemic steroid exposure above physiologic replacement, recent taper, or otherwise suspected suppression
Maintenance inhalers
Neurologic / psychiatric
SSRI / SNRI / TCA / other antidepressant
MAO inhibitor
Antipsychotic / non-lithium mood stabilizer
Lithium
Procedure context
Chronic benzodiazepine
Prescription ADHD stimulant
Amphetamine / methylphenidate class
Antiseizure medication
Parkinson dopaminergic therapy
Pain / opioid use disorder
Chronic opioid therapy
Buprenorphine
Methadone maintenance
Naltrexone
Formulation
NSAID
Other common medications
Levothyroxine / thyroid replacement
Estrogen-containing OCP / HRT
Transplant immunosuppression
Herbal / dietary supplements
Other medication instruction
Optional clinician-entered instruction copied verbatim into the plan
Select medications to generate recommendations.
References
1
Thompson A, Fleischmann KE, Smilowitz NR, et al. 2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM guideline for perioperative cardiovascular management for noncardiac surgery. Circulation. 2024;150:e351-e442. doi:10.1161/CIR.0000000000001285.
View guideline
Primary Cardiac Guideline
2
Canet J, Gallart L, Gomar C, et al. Prediction of postoperative pulmonary complications in a population-based surgical cohort. Anesthesiology. 2010;113(6):1338-1350. doi:10.1097/ALN.0b013e3181fc6e0a.
View ARISCAT study
ARISCAT
3
Mahmud N, Fricker ZP, McElroy LM, Qayed E, Wong RJ, Ioannou GN. ACG clinical guideline: perioperative risk assessment and management in patients with cirrhosis. Am J Gastroenterol. 2025;120(9):1968-1984. doi:10.14309/ajg.0000000000003616.
View ACG guideline
Cirrhosis / Surgical Risk
4
Kim WR, Mannalithara A, Heimbach JK, et al. MELD 3.0: the Model for End-Stage Liver Disease updated for the modern era. Gastroenterology. 2021;161(6):1887-1895.e4. doi:10.1053/j.gastro.2021.08.050.
View MELD 3.0 study
MELD 3.0
5
Douketis JD, Spyropoulos AC. Perioperative management of patients taking direct oral anticoagulants: a review. JAMA. 2024;332(10):825-834. doi:10.1001/jama.2024.12708.
View review
DOAC Management
6
American Diabetes Association Professional Practice Committee for Diabetes. 16. Diabetes care in the hospital: Standards of Care in Diabetes—2026. Diabetes Care. 2026;49(Suppl 1):S339-S355. doi:10.2337/dc26-S016.
View ADA Standards
Perioperative Diabetes
7
Kindel TL, Wang AY, Wadhwa A, et al. Multi-society clinical practice guidance for the safe use of glucagon-like peptide-1 receptor agonists in the perioperative period. Surg Endosc. 2025;39(1):180-183. doi:10.1007/s00464-024-11263-2.
View multi-society guidance
GLP-1 Therapy
8
Beuschlein F, Else T, Bancos I, et al. European Society of Endocrinology and Endocrine Society Joint Clinical Guideline: diagnosis and therapy of glucocorticoid-induced adrenal insufficiency. J Clin Endocrinol Metab. 2024;109(7):1657-1683. doi:10.1210/clinem/dgae250.
View guideline
Perioperative Steroids
9
Douketis JD, Spyropoulos AC, Murad MH, et al. Perioperative management of antithrombotic therapy: an American College of Chest Physicians clinical practice guideline. Chest. 2022;162(5):e207-e243. doi:10.1016/j.chest.2022.07.025.
View guideline
Antithrombotics
10
Oprea AD, Keshock MC, O'Glasser AY, et al. Preoperative management of medications for neurologic diseases: SPAQI consensus statement. Mayo Clin Proc. 2022;97(2):375-396. doi:10.1016/j.mayocp.2021.11.010.
View consensus statement
Neurologic Medications
11
Oprea AD, Keshock MC, O'Glasser AY, et al. Preoperative management of medications for psychiatric diseases: SPAQI consensus statement. Mayo Clin Proc. 2022;97(2):397-416. doi:10.1016/j.mayocp.2021.11.011.
View consensus statement
Psychiatric Medications
12
Kohan L, Potru S, Barreveld AM, et al. Buprenorphine management in the perioperative period: educational review and recommendations from a multisociety expert panel. Reg Anesth Pain Med. 2021;46(10):840-859. doi:10.1136/rapm-2021-103007.
View expert-panel recommendations
Buprenorphine / OUD
13
Sahai SK, Balonov K, Bentov N, et al. Preoperative management of cardiovascular medications: a SPAQI consensus statement. Mayo Clin Proc. 2022;97(9):1734-1751. doi:10.1016/j.mayocp.2022.03.039.
View consensus statement
Cardiovascular Medications
14
Pfeifer KJ, Selzer A, Mendez CE, et al. Preoperative management of endocrine, hormonal, and urologic medications: SPAQI consensus statement. Mayo Clin Proc. 2021;96(6):1655-1669. doi:10.1016/j.mayocp.2020.10.002.
View consensus statement
Endocrine / Hormonal Medications
15
Crotty K, Freedman KI, Kampman KM. Executive summary of the focused update of the ASAM National Practice Guideline for the Treatment of Opioid Use Disorder. J Addict Med. 2020;14(2):99-112. doi:10.1097/ADM.0000000000000635.
View guideline summary
Naltrexone / OUD