Anesthesia Risk Stratification for Cardiac Patients (ASA + Cardiac Modifiers)
Anesthesia Risk Stratification for Cardiac Patients (ASA + Cardiac Modifiers): Explanation and Clinical Context This tool combines the ASA Physical Status (ASA-PS) classification with cardiac-specific “risk modifiers” and the presence of active cardiac conditions to structure perioperative decision-making for patients with cardiovascular disease who are undergoing noncardiac surgery. The ASA-PS conveys baseline physiological reserve and comorbidity burden, and the emergency modifier “E” indicates time-critical surgery. On its own, ASA-PS has limited predictive precision for individual outcomes, so it is paired here with the 2024 AHA/ACC stepwise approach.
Active cardiac conditions (e.g., acute coronary syndrome, decompensated heart failure, unstable arrhythmia, or severe symptomatic valvular disease) signify unstable disease. In elective cases, their presence generally warrants deferral of surgery pending evaluation and optimization. If the case is an emergency, proceed with appropriate monitoring and hemodynamic goals.
Risk modifiers identify states that meaningfully increase perioperative risk beyond baseline comorbidity and surgical stress. They include severe valvular heart disease, severe pulmonary hypertension, adult congenital heart disease at elevated risk, prior coronary stent/CABG, recent stroke/TIA (≤3 months), cardiac implantable electronic device, and frailty. Their presence should trigger multidisciplinary planning about timing, venue, monitoring, and whether additional testing could change management (e.g., ECG for symptomatic CVD; echocardiography for significant valvular disease or new dyspnea).
This calculator does not output a numerical MACE probability because ASA + modifiers is a guideline-aligned triage framework rather than a single validated predictive model. For numeric risk estimation, use a validated index such as RCRI or ACS-NSQIP if results would alter management. Functional capacity (e.g., DASI) and selective biomarkers (BNP/NT-proBNP, ± troponin) can refine assessment in patients at elevated risk or with poor/unknown capacity. The output categories and suggested actions mirror the 2024 AHA/ACC stepwise pathway: 1) defer elective surgery for active conditions; 2) with risk modifiers, elevate vigilance and consider testing; 3) otherwise, proceed based on surgical risk, ASA-PS, and clinical context.
References:
American Society of Anesthesiologists. Statement on ASA Physical Status Classification System. 2020. (Definition and use of ASA-PS, including the “E” emergency modifier.)
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. (Stepwise approach; role of risk modifiers, functional capacity, biomarkers.)
OpenAnesthesia. Preoperative Cardiac Risk Stratification and Evaluation (summary of 2024 guideline; lists active cardiac conditions and risk modifiers).
Doyle DJ, et al. StatPearls: ASA Physical Status Classification System. Updated 2023–2024. (Background and limitations of ASA-PS as a predictive tool.)