ACC on preop EKG:
 
- reasonable for patients with known coronary heart disease, significant arrhythmias, peripheral artery disease, cerebrovascular disease, or other significant structural heart disease, except for those having low-risk surgery (IIa, B)
 
- may be considered for asymptomatic patients without known coronary heart disease, except for those undergoing low-risk surgery (IIb, B)
 
- not useful for asymptomatic patients undergoing low risk surgical procedures (III:NB, B)
 
- timing: ACC notes general consensus that when EKG is warranted, an obtained EKG 1-3 months prior to surgery is adequate for stable patients.  This is more an observation in the guideline rather than a recommendation.
 
ICSI on preop EKG:
 
- agrees with ACC-AHA 2014 recommendations

ACC on preop eval of LV function:

– reasonable for patients with dyspnea of unknown origin (IIa, C)

– reasonable for patients with HF with worsening dyspnea or other change in clinical status (IIa, C)

– reassessment may be considered in clinically stable patients with previously documented LV dysfunction if there has been no assessment within a year (IIb, C)

– routine preop eval of LV function is not recommended (III:NB, B)

ACC on preop eval of valve dz:

– recommended for patients with clinically suspected moderate or greater degrees of valvular stenosis or regurgitation if there has been either (1) no prior echo within 1 year, or (2) a significant change in clinical status or physical exam since last eval (I, C) 

These recommendations endorse a limited role for preop echocardiography. They apply mostly to those with symptoms, severe disease, or both. They are mostly permissive, lukewarm recommendations. The recommendation against routine echo continues. And the evidence does not support clear benefit. The retrospective cohort study (Wijeysundera BMJ 2011, see ref) of 9 years of patients undergoing intermediate to high risk surgery in Ontario hospitals compared 40,000 patients with preop echo to 70,000 propensity-score matched controls (always a tricky study design) without echo. Preop echo was not associated with improved survival or hospital stay

ICSI says consider checking K+ if:

- Patient takes Digoxin, diuretics, ACE inhibitor, or ARB

- check electrolytes for those on lithium

ASA's 2012 guideline mentions testing directed by clinical characteristics including likely perioperative therapies, endocrine disorders, risk of renal and liver dysfunction, and use of certain medications or alternative therapies.  ASA's Choosing Wisely document recommends no preop CBC, BMP or CMP, or coags in patients without significant systemic disease (ASA class I or II) undergoing low-risk surgery when blood loss (or fluid shifts) is/are expected to be minimal.

Do not perform routine preop CXR.

Consider preop CXR if patient has signs or symptoms suggesting new or unstable cardiopulmonary disease.

Not only does the ESA (gr B) guideline review the evidence of no benefit, but 4 different organizations have identified preop CXR as a practice to be discontinued in the Choosing Wisely campaign, namely the American College of Physicians, the American College of Radiology, the American College of Surgeons, and the Society of General Internal Medicine, each offering their own review of the evidence.

ASA states that extremes of age, smoking, stable COPD, stable cardiac disease, or resolved recent upper respiratory infection should not be considered unequivocal indications for chest radiography.

ICSI says routine Hbg/CBC not indicated (strong, low) consider based upon patient’s underlying medication condition and the planned procedure (e.g. pt has history of anemia or history suggesting recent blood loss anemia)

ASA says routine Hgb/CBC not indicated, consider based upon type and invasiveness of procedure, patients with liver disease, extremes of age, and history of anemia, bleeding, and other hematologic disorders.

Preoperative diagnostic spirometry in non-cardiothoracic surgery patients cannot be recommended to evaluate the risk of postoperative complications (ESA D).

Spirometry characterizes obstructive lung disease well, but it does not well predict postoperative complications nor guide demonstrated management improvements.

ASA says routine urinalysis is not indicated except for specific procedures (e.g., prosthesis implantation, urologic procedures) or when urinary tract symptoms are present

A recent Canadian guideline (see ref) recommends pre-operative BNP (or NT-proBNP) and post-operative Troponin on certain (high-risk) patients. 

ACC does not endorse routine screening BNP or Troponin as there is no evidence as of yet to guide how to respond to the results of such tests and their potential impact on care for good or ill.  However, new evidence is emerging.  A large cohort study nested in the recent VISION trial looked at preop BNP, postop troponin levels, and the 30-day outcomes of MINS (myocardial injury after non-cardiac surgery, meaning symptomatic or non-symptomatic rise of troponin without non-ischemic alternate cause), vascular death, and all-cause mortality (Duceppe 2019, see ref).  Elevated preop NT-proBNP was associated with elevated risk of MINS, vascular death, and all-cause mortality.  The article suggests that preop BNP could be used with RCRI to assist in preop risk stratification.  However, no study yet shows that use of this information pre- or post-op improves outcomes.  Pay attention for further studies and incorporation into guidelines.

Note that if signs or symptoms of myocardial ischemia or heart failure develop, then diagnostic testing with these biomarkers and any clinically indicated evaluation is quite appropriate (and explicitly endorsed by ACC).

Various authorities have opinions about the value of additional pre-op tests. For instance, Beta-HCG in reproductive-age women with uncertain pregnancy status, BUN & Creatinine in patients with suspected or known renal disease, etc.

Most importantly, if your knowledge of the patient suggest risk of deranged lytes, renal fxn, pulmonary fxn, etc., and it bears on surgery, you are justified to check any test.

No routine preop testing is indicated.

A Cochrane systematic review of 2012 looked specifically at the value of preop testing before cataract surgery, finding 3 RCT’s of 21,000+ total patients. It found that patients undergoing cataract surgery did have adverse medical events associated with surgery, which is not surprising since patients with cataracts often have numerous other medical comorbidities. However, routine preop testing did not reduce those events during or after surgery compared with no testing at all. The conclusion is that routine preop testing does not improve the safety of cataract surgery.