Article Text

Download PDFPDF
Managing patients undergoing non-cardiac surgery: need to shift emphasis from risk stratification to risk modification
  1. G Karthikeyan,
  2. B Bhargava
  1. Department of Cardiology, All India Institute of Medical Sciences, New Delhi, India
  1. Correspondence to:
    Dr Ganesan Karthikeyan
    Department of Cardiology, Cardiothoracic Sciences Centre, All India Institute of Medical Sciences, New Delhi – 110029, India; karthik_2010{at}


Many patients undergo non-invasive testing for the detection of coronary artery disease before non-cardiac surgery. This is despite the low predictive value of positive tests in this population and the lack of any evidence of benefit of coronary revascularisation before non-cardiac surgical procedures. Further, this strategy often triggers a clinical cascade exposing the patient to progressively riskier testing and intervention and results in increased costs and unnecessary delays. On the other hand, administration of β blockers, and more recently statins, has been shown to reduce the occurrence of perioperative ischaemic events. Therefore, there is a need for a shift in emphasis from risk stratification by non-invasive testing to risk modification by the application of interventions, which prevent perioperative ischaemia—principally, perioperative β adrenergic blockade and perhaps treatment with statins. Clinical risk stratification tools reliably identify patients at high risk of perioperative ischaemic events and can guide in the appropriate use of perioperative medical treatment.

  • CABG, coronary artery bypass grafting
  • CAD, coronary artery disease
  • CASS, coronary artery surgery study
  • DSE, dobutamine stress echocardiogram
  • MI, myocardial infarction
  • NWMA, new wall motion abnormalities
  • perioperative risk
  • non-cardiac surgery
  • preoperative evaluation
  • β adrenergic blockers

Statistics from

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.


  • GK wishes to thank Professor KR Sethuraman for introducing him to Brer Rabbit and Tar-Baby

  • Competing interests: none