Study guide
18.1 Preoperative Cardiovascular Risk Assessment
ABIM Internal Medicine Exam
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1 Chapter 0: The ABIM Exam, Blueprint & Study Strategy
0.1 Exam Format, Question Types & the 2026 Blueprint 0.2 Eligibility, Registration, Fees & Exam-Day Logistics 0.3 Scoring, the Passing Standard & Score Reports 0.4 Building a Blueprint-Weighted Study Plan
2 Chapter 1: Cardiovascular Disease (14% of Exam)
1.1 Ischemic Heart Disease & Acute Coronary Syndromes 1.2 Antithrombotic Therapy, Secondary Prevention & Mechanical Complications of MI 1.3 Atrial Fibrillation, Atrial Flutter & Stroke Prevention 1.4 Supraventricular Tachycardias, Ventricular Arrhythmias & Bradycardias 1.5 Heart Failure: Classification, Staging & Guideline-Directed Medical Therapy 1.6 Device Therapy, HFpEF & the Cardiomyopathies 1.7 Valvular Heart Disease & Endocarditis Prophylaxis 1.8 Pericardial Disease & Acute Aortic Syndromes 1.9 Hypertension: Classification, Diagnosis & Secondary Causes 1.10 Hypertensive Crises & Dyslipidemia 1.11 Adult Congenital Heart Disease & Coarctation of the Aorta 1.12 Syncope: Reflex, Orthostatic & Cardiac Causes 1.13 Cardiac Physical Examination, Murmurs & Antithrombotic Selection
3 Chapter 2: Endocrinology, Diabetes & Metabolism (9% of Exam)
2.1 Diabetes Mellitus: Diagnosis, Glycemic Targets & Pharmacotherapy 2.2 Insulin Therapy, Hyperglycemic Emergencies & Chronic Complications 2.3 Thyroid Function Testing & Hypothyroidism 2.4 Thyrotoxicosis, Thyroid Storm & Thyroid Nodules 2.5 Adrenal & Pituitary Disorders 2.6 Hypercalcemia, Hypocalcemia & Disorders of Mineral Metabolism 2.7 Osteoporosis & Paget Disease of Bone 2.8 Ovarian, Testicular & Reproductive Endocrine Disorders 2.9 Hypoglycemia, Endocrine Tumors, Polyglandular Syndromes & Severe Hypertriglyceridemia
4 Chapter 3: Gastroenterology & Hepatology (9% of Exam)
3.1 Esophageal Disease 3.2 Stomach & Duodenal Disease and Gastrointestinal Hemorrhage 3.3 Inflammatory Bowel Disease 3.4 Celiac Disease & Irritable Bowel Syndrome 3.5 Diverticular Disease & Colorectal Cancer Screening 3.6 Viral Hepatitis, Steatotic & Alcohol-Associated Liver Disease 3.7 Cirrhosis & the Complications of Portal Hypertension 3.8 Acute Pancreatitis 3.9 Chronic Pancreatitis & Biliary Tract Disease 3.10 Inherited, Autoimmune & Drug-Induced Liver Disease 3.11 Small Intestinal Disease, Ischemia & Gastrointestinal Complications of HIV
5 Chapter 4: Infectious Disease (9% of Exam)
4.1 Lower Respiratory Tract Infections & Sepsis Syndromes 4.2 Viral Respiratory Pathogens & Tuberculosis 4.3 Central Nervous System Infections 4.4 Skin, Soft Tissue, Bone & Joint Infections 4.5 Infective Endocarditis & Cardiovascular Infection 4.6 Clostridioides difficile & Catheter-Related Bloodstream Infection 4.7 HIV Diagnosis, Antiretroviral Therapy & Prevention 4.8 Opportunistic Infections & Sexually Transmitted Infections 4.9 Fever of Unknown Origin, Neutropenic Fever & Toxic Shock 4.10 Travel-Related Illness, Vector-Borne Disease & Outbreaks 4.11 Infection Prevention, Nosocomial Infection & Postexposure Prophylaxis 4.12 Rheumatic Fever, Poststreptococcal Disease, Enteric & Hepatic Infections
6 Chapter 5: Pulmonary Disease (9% of Exam)
5.1 COPD: Diagnosis, GOLD Classification & Initial Pharmacotherapy 5.2 Interventions That Reduce COPD Mortality & Exacerbation Management 5.3 Asthma: Diagnosis, Stepwise Therapy & Status Asthmaticus 5.4 Interstitial Lung Disease & Idiopathic Pulmonary Fibrosis 5.5 Sarcoidosis, Hypersensitivity Pneumonitis & Occupational Lung Disease 5.6 Pulmonary Embolism: Diagnosis, Risk Stratification & Anticoagulation 5.7 Pulmonary Hypertension & Sleep-Disordered Breathing 5.8 Acute Respiratory Distress Syndrome & Mechanical Ventilation 5.9 Pleural Disease, Empyema & Pneumothorax 5.10 Bronchiectasis, Cystic Fibrosis & Restrictive Lung Disease 5.11 Evaluation of Cough, Dyspnea, Hemoptysis & the Solitary Pulmonary Nodule
7 Chapter 6: Rheumatology & Orthopedics (9% of Exam)
6.1 Rheumatoid Arthritis: Diagnosis & Systemic Manifestations 6.2 Antirheumatic Pharmacotherapy & the Spondyloarthropathies 6.3 Gout: Pathophysiology & Acute Management 6.4 Urate-Lowering Therapy & Calcium Pyrophosphate Deposition Disease 6.5 Osteoarthritis 6.6 Systemic Lupus Erythematosus 6.7 Systemic Sclerosis, Sjogren Syndrome & Inflammatory Myopathies 6.8 The Vasculitides 6.9 Regional Musculoskeletal Syndromes, Back Pain & Sports Injuries 6.10 Other Primary Rheumatic Disorders & Mixed Connective Tissue Disease 6.11 Osteonecrosis & Metabolic Bone Disease
8 Chapter 7: Hematology (6% of Exam)
7.1 Approach to Anemia & the Microcytic Anemias 7.2 Macrocytic, Normocytic & Hemolytic Anemias 7.3 Hemoglobinopathies, Thalassemias & Paroxysmal Nocturnal Hemoglobinuria 7.4 Platelet Disorders, Thrombocytopenia & the Bleeding Patient 7.5 Coagulation Factor Disorders, Thrombophilia & Anticoagulant Reversal 7.6 Acute Leukemias, Chronic Leukemias & Myeloproliferative Neoplasms 7.7 Lymphomas & Plasma Cell Disorders 7.8 Myelodysplastic Syndrome, Myeloproliferative Neoplasms & Porphyria 7.9 Transfusion Medicine & Late Complications of Transplantation
9 Chapter 8: Medical Oncology (6% of Exam)
8.1 Breast, Lung, Colorectal & Prostate Cancer 8.2 Oncologic Emergencies 8.3 Genitourinary & Gynecologic Malignancies 8.4 Head and Neck, Bone & Soft Tissue Cancer and Cancer of Unknown Primary 8.5 Complications of Cancer & Its Treatment 8.6 Cancer Prevention, Survivorship & Psychosocial Care
10 Chapter 9: Nephrology & Urology (6% of Exam)
9.1 Acute Kidney Injury: Staging, Etiology & Urine Microscopy 9.2 Glomerular Disorders & Nephrotic Syndrome 9.3 Nephritic Syndromes, RPGN & Indications for Renal Replacement Therapy 9.4 Chronic Kidney Disease: Staging & Progression Retardation 9.5 Complications of Chronic Kidney Disease: Anemia, CKD-MBD & Acidosis 9.6 Hyponatremia, Hypernatremia & Water Balance 9.7 Potassium Disorders & Systematic Acid-Base Analysis 9.8 Renal Tubular Acidosis & Nephrolithiasis 9.9 Prostate Disorders, Urinary Incontinence & Other Urologic Conditions 9.10 Cystic Kidney Disease, Obstructive Uropathy, Tubulointerstitial Disease & Hematuria
11 Chapter 10: Neurology (4% of Exam)
10.1 Acute Ischemic Stroke: Syndromes & Reperfusion 10.2 Transient Ischemic Attack, Secondary Prevention & Hemorrhagic Stroke 10.3 Headache & Facial Pain 10.4 Seizures, Epilepsy & Movement Disorders 10.5 Multiple Sclerosis & Neuromuscular Junction Disorders 10.6 Motor Neuron Disease & Acute Peripheral Neuropathy 10.7 Cranial Neuropathies & Neuro-Ophthalmology 10.8 Peripheral Neuropathies, CNS Tumors & Other Neurologic Disorders
12 Chapter 11: Psychiatry & Behavioral Health (4% of Exam)
11.1 Major Depressive Disorder & Medical Mimics 11.2 Antidepressant Pharmacotherapy & Treatment-Resistant Depression 11.3 Bipolar Disorder, Mood Stabilizers & Lithium Toxicity 11.4 Anxiety, Stress-Related & Obsessive-Compulsive Disorders 11.5 Alcohol Use Disorder & Withdrawal 11.6 Pharmacotherapy for Alcohol & Opioid Use Disorder 11.7 Toxidromes, Psychiatric Emergencies & Suicide Risk Assessment 11.8 Psychotic, Somatic Symptom, Factitious & Personality Disorders 11.9 Eating Disorders, Sleep Disorders & Sexual Health
13 Chapter 12: Dermatology (3% of Exam)
12.1 Dermatitis, Papulosquamous & Inflammatory Dermatoses 12.2 Acne, Rosacea & Cutaneous Infections 12.3 Herpes Zoster & Autoimmune Blistering Diseases 12.4 Nodules, Tumors & Cutaneous Oncology 12.5 Dermatologic Emergencies & Severe Cutaneous Adverse Reactions 12.6 Pigment Disorders, Alopecia, Nail Disease & Photosensitivity 12.7 Vascular Dermatoses, Environmental Injury & Cutaneous Signs of Systemic Disease
14 Chapter 13: Obstetrics & Gynecology / Women's Health (3% of Exam)
13.1 Contraception, Preconception Care & Teratogenicity 13.2 Hypertensive Disorders of Pregnancy & Gestational Diabetes 13.3 Thyroid Disease & Venous Thromboembolism in Pregnancy 13.4 Menopause & Menopausal Hormone Therapy 13.5 Abnormal Uterine Bleeding, Endometrial Disease & Gynecologic Cancer Screening 13.6 Breast Disorders & Diseases of the Vulva and Vagina 13.7 Menstrual Disorders, Fibroids, Endometriosis & Early Pregnancy Complications
15 Chapter 14: Geriatric Syndromes (3% of Exam)
14.1 Comprehensive Geriatric Assessment & Frailty 14.2 Falls, Gait Assessment & Polypharmacy 14.3 Urinary Incontinence & Pressure Injuries in Older Adults 14.4 Mild Cognitive Impairment, Dementia & Its Subtypes 14.5 Delirium & the Pharmacotherapy of Cognitive Disorders 14.6 Palliative Care, Hospice & Advance Care Planning 14.7 Chronic Wounds, Nutrition, Swallowing, Constipation & Hip Fracture 14.8 Sensory Impairment, Dizziness, Elder Mistreatment & Care Settings
16 Chapter 15: Allergy & Immunology (2% of Exam)
15.1 Anaphylaxis: Recognition & Emergency Management 15.2 Urticaria & Angioedema 15.3 Drug Allergy, Desensitization & Adult Immunodeficiency 15.4 Food Allergy, Insect Venom Hypersensitivity, Serum Sickness & Contrast Reactions 15.5 Rhinitis, Conjunctivitis, Eosinophilic & Mast Cell Disorders
17 Chapter 16: Preventive Medicine, Immunization & Clinical Epidemiology
16.1 The USPSTF Framework & Evidence-Based Cancer Screening 16.2 Cardiovascular & Metabolic Screening and Primary Prevention 16.3 Adult Immunization & Vaccines in Special Populations 16.4 Clinical Epidemiology, Biostatistics & Study Design
18 Chapter 17: Miscellaneous - Ethics, Patient Safety & Quality Improvement (2% of Exam)
17.1 Principles of Bioethics & Decisional Capacity 17.2 Informed Consent, Treatment Refusal & Special Scenarios 17.3 Surrogate Decision-Making, Advance Directives & Confidentiality 17.4 Patient Safety Science, Medical Error & Diagnostic Reasoning 17.5 Quality Improvement Methods, Health Disparities & Health Equity
19 Chapter 18: Perioperative Medicine & Medical Consultation
18.1 Preoperative Cardiovascular Risk Assessment 18.2 Preoperative Pulmonary Risk & Perioperative Medication Management 18.3 Perioperative Anticoagulation, Bridging & Postoperative Complications
20 Chapter 19: Ophthalmology (1% of Exam)
19.1 The Acute Red Eye & Ophthalmic Emergencies 19.2 Painless Vision Loss & Chronic Ophthalmic Disease 19.3 Uveitis, Scleritis & Orbital Disease
21 Chapter 20: Otolaryngology & Dental Medicine (1% of Exam)
20.1 Dizziness, Vertigo & Epistaxis 20.2 Ear Disorders, Hearing Loss & Upper Respiratory Infections 20.3 Oral Cavity, Salivary Gland, Laryngeal & Taste and Smell Disorders
18.1 Preoperative Cardiovascular Risk Assessment
Key Takeaways Explain This Topic AI
Preoperative consultation is a named Cardiovascular Disease blueprint subsection listing no testing required and testing indicated.
Functional capacity of four metabolic equivalents or greater generally obviates further cardiac testing before non-cardiac surgery.
Testing is justified only when the result would change perioperative management, not to document risk.
Elective non-cardiac surgery is deferred after myocardial infarction and after coronary stenting for a guideline-specified interval.
Emergency surgery proceeds without cardiac testing, with risk mitigation and perioperative monitoring instead.
Last updated: August 2026
Perioperative medical consultation is a core competency in internal medicine. The primary goal is not to "clear" a patient for surgery, but rather to perform an evidence-based risk stratification, identify modifiable clinical risk factors, optimize chronic medical conditions, formulate perioperative medication plans, and anticipate and manage postoperative complications.
1. Preoperative Cardiovascular Risk Assessment
Cardiovascular complications—including myocardial infarction (MI), acute heart failure, malignant arrhythmias, and cardiac arrest—are the leading causes of perioperative morbidity and mortality in noncardiac surgery.
Revised Cardiac Risk Index (RCRI / Lee Index)
The Revised Cardiac Risk Index (RCRI) is the most widely validated clinical tool for estimating perioperative Major Adverse Cardiac Events (MACE: defined as myocardial infarction, pulmonary edema, ventricular fibrillation, primary cardiac arrest, or complete heart block).
RCRI Clinical Predictors (1 Point Each) Specific Clinical Definitions & Criteria
1. High-Risk Surgery Intraperitoneal, intrathoracic, or suprainguinal vascular procedures (e.g., aortic aneurysm repair, peripheral arterial bypass, pneumonectomy, Whipple procedure)
2. Ischemic Heart Disease History of myocardial infarction, positive prior stress test, current angina pectoris, use of sublingual/oral nitrates, or pathological Q waves on baseline ECG
3. History of Congestive Heart Failure Prior heart failure hospitalization, history of pulmonary edema, paroxysmal nocturnal dyspnea, peripheral edema, S3 gallop, bilateral crackles, or documented systolic/diastolic dysfunction
4. Cerebrovascular Disease History of transient ischemic attack (TIA) or ischemic/hemorrhagic stroke
5. Insulin-Dependent Diabetes Mellitus Diabetes mellitus requiring preoperative treatment with subcutaneous or IV insulin (oral hypoglycemic monotherapy does not count)
- 6. Renal Insufficiency Preoperative serum creatinine > 2.0 mg/dL (> 177 mcmol/L)
- Risk Stratification by RCRI Score
- Class I (0 Points): 3.9% baseline risk of major adverse cardiac events (Low Risk)
- Class II (1 Point): 6.0% risk of major adverse cardiac events (Low-to-Moderate Risk)
- Class III (2 Points): 10.1% risk of major adverse cardiac events (Moderate Risk)
- Class IV (>= 3 Points): 15.0% risk of major adverse cardiac events (High Risk)
- ACC/AHA Stepped Perioperative Cardiovascular Algorithm
The American College of Cardiology / American Heart Association (ACC/AHA) guidelines outline a systematic 5-step clinical decision algorithm for evaluating cardiac risk prior to elective noncardiac surgery:
Step 1 — Emergency Surgery: Determine surgical urgency. If the surgery is an emergency (life- or limb-threatening procedure where delay significantly increases morbidity/mortality, e.g., ruptured aortic aneurysm, perforated viscus, acute compartment syndrome), proceed directly to the operating room without cardiac testing. Perform clinical risk assessment and cardiac surveillance postoperatively.
Step 2 — Active Cardiac Conditions: Screen for unstable, active cardiac conditions that mandate immediate cardiology evaluation and optimization before elective surgery:
Acute Coronary Syndromes (ACS): Unstable angina, recent acute myocardial infarction (< 30–60 days).
Decompensated Heart Failure: NYHA Class IV symptoms, worsening dyspnea at rest, new/worsened pulmonary edema.
Significant Arrhythmias: High-grade AV block (Mobitz II second-degree or third-degree heart block), symptomatic ventricular arrhythmias, newly recognized supraventricular tachycardias or atrial fibrillation with rapid ventricular response (RVR).
Severe Symptomatic Valvular Heart Disease: Severe symptomatic aortic stenosis (mean aortic valve gradient >= 40 mmHg, peak velocity >= 4.0 m/s, or aortic valve area < 1.0 cm2) or severe symptomatic mitral stenosis. (Symptomatic severe AS requires surgical or transcatheter aortic valve replacement [TAVR/SAVR] prior to elective noncardiac surgery).
Step 3 — Low-Risk Surgical Procedures: If the procedure has a low estimated MACE risk ( < 1% ; e.g., cataract extraction, minor dermatologic/superficial excisions, breast biopsy, diagnostic endoscopy), proceed directly to surgery without any preoperative cardiac testing, regardless of patient comorbidities.
Step 4 — Functional Capacity Assessment in Elevated-Risk Surgery: For procedures with elevated risk ( >= 1% MACE ; e.g., major orthopedic arthroplasty, intra-abdominal, intrathoracic, or vascular surgery), assess functional capacity measured in Metabolic Equivalents of Task (METs) :
Good to Excellent Functional Capacity (>= 4 METs): Able to climb a flight of stairs or walk up a hill without stopping, walk on level ground at 4 mph (6.4 km/h), carry heavy groceries, or perform heavy housework. Patients with >= 4 METs can proceed directly to surgery without further cardiac testing , even if they have an elevated RCRI score.
Poor or Unknown Functional Capacity (< 4 METs): Unable to walk 2 blocks on level ground or climb 1 flight of stairs without stopping due to dyspnea, angina, or severe physical deconditioning/osteoarthritis.
Step 5 — Selective Cardiac Testing: In patients with poor or unknown functional capacity (< 4 METs) undergoing elevated-risk surgery:
If the patient has an elevated RCRI score (>= 1) and non-invasive stress testing will change clinical management (e.g., prompt coronary revascularization for high-risk CAD or influence surgical decision-making), obtain a non-invasive Pharmacologic Stress Test ( Dobutamine Stress Echocardiography or Vasodilator Myocardial Perfusion Imaging [MPI] with Regadenoson/Adenosine SPECT).
If stress testing will not change clinical management (e.g., patient is not a revascularization candidate or the surgical plan will proceed regardless), proceed to the OR with medical optimization.
Crucial Board Rule: Routine preoperative coronary angiography or prophylactic coronary revascularization (CABG/PCI) in stable patients prior to noncardiac surgery is NOT recommended (CARP and DECREASE-V trials demonstrated no reduction in perioperative mortality or MI compared to medical optimization).
Loading diagram... ACC/AHA Preoperative Cardiovascular Evaluation Algorithm
Preoperative Beta-Blocker Management
Chronic Beta-Blocker Therapy: Patients receiving chronic beta-blocker therapy (for CAD, heart failure, arrhythmias, or hypertension) MUST continue their beta-blocker throughout the entire perioperative period . Abrupt cessation on the day of surgery causes acute sympathetic rebound, tachycardia, severe hypertension, myocardial ischemia, and significantly increased perioperative mortality.
Beta-Blocker-Naive Patients: NEVER start high-dose beta-blockers acutely on the morning of surgery . Landmark trial evidence ( POISE Trial ) showed that initiating high-dose oral metoprolol succinate on the day of surgery reduced nonfatal myocardial infarction but resulted in a statistically significant increase in total mortality, severe intraoperative hypotension, and fatal/disabling ischemic strokes .
Guideline Recommendation: If a beta-blocker is clinically indicated in a high-risk, beta-blocker-naive patient (e.g., known CAD undergoing high-risk vascular surgery), it must be initiated days to weeks (ideally > 7 to 30 days) prior to elective surgery and slowly titrated to a target resting heart rate of 60–80 bpm while ensuring systolic blood pressure remains >= 100 mmHg.