## Major Clinical Predictors of Perioperative Cardiac Risk **Key Point:** Major clinical predictors are conditions that carry the highest risk of perioperative cardiac complications and typically require intervention (coronary revascularization, optimization, or cancellation of elective surgery) before proceeding with non-cardiac surgery. ### ACC/AHA Classification of Cardiac Risk Predictors | Category | Examples | Perioperative Action | |----------|----------|---------------------| | **Major Predictors** | Unstable angina, recent MI (≤1 mo), decompensated HF, significant arrhythmias, severe valvular disease | Delay elective surgery; consider revascularization or intensive monitoring | | **Intermediate Predictors** | Stable angina, prior MI (>1 mo), compensated HF, diabetes, renal insufficiency | Risk stratify; optimize medical therapy; consider stress testing | | **Minor Predictors** | Advanced age, abnormal ECG, LVH, hypertension, obesity | Proceed with surgery; perioperative monitoring | **High-Yield:** Unstable angina and recent MI (within 1 month) are **major predictors**. Recent MI is defined as ≤1 month before surgery; beyond 1 month, it becomes an intermediate predictor. **Clinical Pearl:** The ACC/AHA guidelines recommend that elective surgery be postponed in patients with major predictors until the condition is stabilized or revascularized. Emergency surgery may proceed with intensive perioperative monitoring and optimization. **Mnemonic:** SAVER for major predictors — **S**evere valvular disease, **A**cute coronary syndrome (unstable angina/recent MI), **V**entricular dysfunction (decompensated), **E**mergent arrhythmias, **R**ecent MI. ### Why Unstable Angina / Recent MI Is Major These conditions represent active myocardial ischemia or necrosis with high risk of perioperative MI, cardiogenic shock, or death. They mandate preoperative intervention or surgery delay [cite:Harrison 21e Ch 47].
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