Perioperative assessment
Preoperative Risk Assessment
RCRI, ARISCAT, and DASI in one place. Review the inputs, consult medication references, and prepare a concise, editable assessment and plan.
Educational tool. This tool does not provide medical advice or replace clinical judgment. Generated text is an editable draft for manual copying, not a complete preoperative assessment. Review and verify all results, recommendations, and any optimization statement before including them in a clinical note.
Inputs stay in this browser tab. Nothing entered here is saved or sent to MendelMD. Do not enter patient identifiers.
These scores do not assess acute coronary syndrome, decompensated heart failure, unstable arrhythmia, severe valvular disease, pulmonary hypertension, recent stroke, prior PCI/CABG, cardiac devices, or frailty. Assess these separately. For emergency surgery, scoring must not delay urgent care; coordinate with the surgical and anesthesia teams. A low score does not exclude these risks.
1. Procedure
Procedure risk guidance (ACC/AHA)
Contemporary cardiac assessment combines patient and procedural factors to estimate perioperative major adverse cardiovascular event (MACE) risk: low (<1%) or elevated (≥1%). The RCRI surgery criterion alone does not assign that category.
2026 AHA/ACC reaffirmation ↗2. Risk scores
Open each score to answer. Unknown answers keep it incomplete and out of the note.
RCRINot startedAnswer every question to calculate.
Six clinical factors, one point each. The procedure criterion above is shared with this score. Percentages are pooled 30-day estimates of myocardial infarction, cardiac arrest, or death from CCS 2017, not individualized predictions.
Surgery criterion: Unknown — change in Procedure above.
The criterion is strictly >2.0 mg/dL; exactly 2.0 does not add a point. Leave blank if unknown.
CCS 2017 risk estimates ↗: 0 points = 3.9%; 1 = 6.0%; 2 = 10.1%; ≥3 = 15.0%. These pooled reference rates estimate MI, cardiac arrest, or death within 30 days. The CCS guideline addresses inpatient noncardiac surgery in adults ≥45, or ages 18–44 with significant cardiovascular disease. They are not individualized predictions and should not be compared directly with the ACC/AHA 1% MACE threshold. Scores 3–6 share the ≥3 category.
ARISCATNot startedAnswer every question to calculate.
Seven factors estimate postoperative pulmonary complication risk: low <26, intermediate 26–44, high ≥45 points. Developed in adult in-hospital surgery; applicability depends on setting.
Leave blank if unknown.
Measure by pulse oximetry while supine, breathing room air. Whole percent; leave blank if unknown.
Hemoglobin ≤10 g/dL adds 11 points. Leave blank if unknown.
Assess separately from the RCRI procedure category.
Original Table 6: ≤2 hours = 0; >2 to 3 = 16; >3 = 23 points. Leave blank if unknown.
DASINot started0/12 activities answered · 12 remaining — select Yes or No for each activity.
Answer for the patient’s ability to perform each activity. The 12 weighted activities total up to 58.2; estimated METs = (0.43 × DASI + 9.6) / 3.5. These are formula-derived questionnaire estimates, not exercise-test measurements, and should not be used to classify patients against the perioperative 4-MET threshold. Derived METs are excluded from the copied note.
DASI enters the note automatically after all 12 activities have a Yes or No answer. Unknown is not counted as No.
DASI ≤34 is a guideline threshold associated with higher 30-day death or myocardial infarction in the METS cohort. Interpret DASI with age, clinical risk, and other findings; a score above 34 does not establish readiness for surgery or determine testing.
3. Medication references (optional)
Review timing and exceptions, then insert only the reminders relevant to your note. These are draft considerations, not medication orders.
Browse medication timing references (10 classes)
Usually 3 days; ertugliflozin 4
Exceptions & sources
Elective surgery guidance generally withholds SGLT2 inhibitors for 3 days (ertugliflozin 4) because of perioperative ketoacidosis risk, including euglycemic DKA. Recent dosing or urgent surgery needs anesthesia review; restart requires clinical stability and oral intake.
- This also applies when an SGLT2 inhibitor is used for heart failure or kidney disease without diabetes; check the actual product label.
- Combination products need the SGLT2 interval too: ertugliflozin/metformin (Segluromet) requires at least 4 days when possible.
- Urgent surgery and recent dosing require an individualized ketoacidosis monitoring plan.
- Do not restart solely because surgery is over; confirm clinical stability and resumed oral intake.
Source checked 2026-11-07. Educational reference; verify the individual plan.
Generally continue
Exceptions & sources
Continue established, stable beta-blocker therapy when clinically appropriate. Do not initiate on the day of surgery solely for prophylaxis; a new indication needs time for tolerability assessment and titration.
- Abrupt withdrawal of chronic beta-blockers can cause harm; continuation through admission and discharge is generally appropriate unless contraindicated.
- Hemodynamic instability may require individualized management.
- For a new long-term indication before elective surgery, initiation is preferably more than 7 days beforehand to assess tolerability and titrate; this is not a universal minimum or a reason to start prophylaxis on surgery day.
Source checked 2026-11-07. Educational reference; verify the individual plan.
Continue; consider starting if indicated
Exceptions & sources
Continue statins in patients already taking them to reduce perioperative cardiovascular events. If temporarily interrupted, review resumption when feasible. For untreated patients who meet statin criteria based on ASCVD history or 10-year risk, perioperative initiation with intended long-term use is recommended.
- The initiation recommendation applies to patients who meet long-term statin criteria, not blanket short-term prophylaxis.
- When a statin is indicated, obtaining LDL cholesterol should not delay surgery.
- Consider the usual contraindications and drug interactions.
Source checked 2026-11-07. Educational reference; verify the individual plan.
Depends on indication
Exceptions & sources
For selected patients taking RAAS inhibitors for controlled hypertension before elevated-risk surgery, omission 24 hours before surgery may limit hypotension. Continuation is reasonable for HFrEF; ARNI-specific decisions require indication and local anesthesia review.
- In the Stop-or-Not ACEi/ARB trial, withholding reduced intraoperative hypotension without a demonstrated reduction in 28-day death or major complications; this does not establish an ARNI rule.
- If interrupted, review resumption once hemodynamically stable and otherwise clinically appropriate.
- Do not apply the hypertension omission approach automatically to HFrEF.
- The guideline reports no perioperative harm/benefit data specific to sacubitril/valsartan (ARNI); confirm the plan with the treating and anesthesia teams.
Source checked 2026-11-07. Educational reference; verify the individual plan.
Individualize
Exceptions & sources
Review volume status, potassium, kidney function, blood pressure, and the heart failure indication. UKCPA monographs generally advise continuation of furosemide and spironolactone, with monitoring; local anesthesia protocols and individual circumstances may differ.
- Correct relevant electrolyte disturbances and avoid hypovolemia.
- MRA use requires particular attention to hyperkalemia and renal dysfunction.
- For thiazides, use the local perioperative protocol; the furosemide/spironolactone guidance is not a thiazide rule.
Source checked 2026-11-07. Educational reference; verify the individual plan.
Check institutional policy
Exceptions & sources
Recommendations differ: the AHA/ACC guideline (reaffirmed 2026) considers continuation reasonable, while ADA 2026 advises holding on the day of surgery or a procedure. FDA labeling advises temporary discontinuation while food and fluid intake is restricted. Review institutional policy, expected fasting duration, renal function, and contrast exposure.
- Guideline disagreement is intentional here; this card does not select a universal hold rule.
- Suspected AKI, hypoxia, hemodynamic instability, or restricted food/fluid intake need separate review before continuation or restart.
- FDA labeling contraindicates metformin at eGFR below 30. Iodinated-contrast restrictions include eGFR 30–60, hepatic disease, alcoholism, heart failure, or intra-arterial contrast; review the product label and local radiology protocol, with eGFR reassessed 48 hours after the imaging procedure and restart only if renal function is stable.
Source checked 2026-11-07. Educational reference; verify the individual plan.
Regimen-specific adjustment
Exceptions & sources
Fasting and perioperative glucose monitoring require an individualized insulin plan. Basal insulin must not be omitted in type 1 diabetes; dose adjustments and pump management are outside this reference.
- This reference does not calculate doses or provide pump orders.
- Coordinate timing, monitoring, and hypoglycemia precautions with the perioperative team.
Source checked 2026-11-07. Educational reference; verify the individual plan.
Individualize aspiration assessment
Exceptions & sources
Multisociety guidance allows most patients to continue GLP-1 therapy, with individualized assessment of aspiration risk. Dose escalation, significant gastrointestinal symptoms, higher doses, and delayed gastric emptying may require a modified anesthesia plan; avoid a blanket hold.
- Review oral and injectable formulations, including semaglutide and dual GIP–GLP-1 therapy such as tirzepatide.
- US multisociety guidance uses individualized risk assessment; higher-risk patients may need a 24-hour liquid diet, further assessment, or deferral under the anesthesia plan.
- Australian/New Zealand guidance recommends continuation with a 24-hour clear-fluid diet for all users. These approaches differ; follow local anesthesia and fasting protocols.
- Higher-risk features also include weekly dosing and other causes of delayed gastric emptying.
- ADA 2026 notes that the required interruption duration is unknown; a 1-week pause of a weekly medicine may not sufficiently reduce retained gastric contents. Do not assume a pause makes aspiration risk absent.
- The anesthesia team may consider gastric ultrasound where available. If interruption is chosen, arrange alternative glycemic management when needed.
- Balance aspiration concerns against hyperglycemia and the effects of interrupting therapy.
Source checked 2026-11-07. Educational reference; verify the individual plan.
Check PCI and bleeding risk
Exceptions & sources
The plan depends on the indication, PCI and stent timing, dual antiplatelet therapy, and procedural bleeding risk. Premature interruption after PCI can be hazardous; coordinate with cardiology, surgery, and anesthesia rather than applying a universal hold.
- After prior PCI, guidelines recommend continuing aspirin if possible, balancing bleeding and thrombotic risks with the perioperative team.
- When time-sensitive noncardiac surgery is necessary within 30 days of a bare-metal stent or less than 3 months after a drug-eluting stent, guidelines favor continuing dual antiplatelet therapy unless bleeding risk outweighs protection against stent thrombosis; coordinate with cardiology, surgery, and anesthesia.
- After prior PCI, if oral anticoagulant monotherapy must be interrupted for noncardiac surgery, guidelines recommend temporary aspirin substitution when feasible until anticoagulation can safely resume; confirm the individual bleeding-risk and restart plan.
- For CAD without prior PCI undergoing elective noncarotid noncardiac surgery, routine perioperative aspirin initiation provides no benefit.
- Without prior PCI, continuing existing aspirin may be reasonable in selected patients whose cardiac risk outweighs bleeding risk; this is different from starting it.
- Do not infer an interruption interval without identifying the drug and procedure.
- Neuraxial procedures need separate anesthesia guidance.
Source checked 2026-11-07. Educational reference; verify the individual plan.
Individual interruption / restart plan
Exceptions & sources
Assess the specific drug, renal function, thrombotic indication, bleeding risk, and restart timing. Neuraxial and deep plexus procedures have distinct safety intervals; bridging is not routine and requires an individualized decision.
- No dose, interruption interval, or bridging algorithm is supplied by this tool.
- Coordinate neuraxial or deep plexus procedures with anesthesia using current ASRA guidance.
Source checked 2026-11-07. Educational reference; verify the individual plan.
Reference version 2026-11-07.4. Source references checked 7 November 2026; educational considerations, not medication orders.
How to use these results
These tools support adult perioperative education and documentation. RCRI summarizes six cardiac risk factors; ARISCAT estimates pulmonary complication risk; DASI describes self-reported functional capacity. Each addresses a different part of an assessment. The draft adds a deterministic summary of completed scores: RCRI >1 identifies elevated cardiac risk, ARISCAT supplies the pulmonary risk category, and DASI ≤34 identifies a threshold associated with higher 30-day death or myocardial infarction in the METS cohort. RCRI 0–1 does not independently establish low overall cardiac risk. Medical optimization is included only after explicit clinician confirmation. For emergency procedures, confirmation instead records review of perioperative considerations without declaring optimization or a decision to proceed. Scores alone do not establish surgical clearance or select further testing.
Unknown answers suppress the corresponding score. RCRI percentages use CCS 2017 pooled estimates of myocardial infarction, cardiac arrest, or death within 30 days of noncardiac surgery; an individual’s risk may differ. DASI-derived METs are questionnaire estimates, not directly measured exercise capacity, and are excluded from copied notes. They should not be interpreted against the perioperative 4-MET threshold.
Scoring methods and original references
- Lee et al., 1999 — original RCRI ↗. One point for each criterion; creatinine must be greater than 2.0 mg/dL. Percentage estimates come from the 2017 CCS guideline ↗: 3.9%, 6.0%, 10.1%, and 15.0% for scores 0, 1, 2, and ≥3. The CCS guideline addresses inpatient noncardiac surgery in adults age ≥45, or age 18–44 with significant cardiovascular disease. Its reference rates are not the ACC/AHA 1% MACE classification. These pooled 30-day estimates use a different endpoint from the original Lee study and do not determine surgical clearance.
- Canet et al., 2010 — original ARISCAT ↗. Table 6 assigns 0 points for duration ≤2 hours, 16 for >2 to 3 hours, and 23 for >3 hours; anemia is ≤10 g/dL. Some calculator implementations use a different two-hour boundary. Both MendelMD ARISCAT tools follow the original scoring table. The original abstract says “at least 2 hours,” whereas Table 6 specifies more than 2 hours for the 16-point category. Table 7 defines low <26, intermediate 26–44, and high ≥45.
- Hlatky et al., 1989 — original DASI ↗. Activity descriptions are paraphrased; validated weights are preserved. Estimated peak VO₂ = 0.43 × DASI + 9.6 mL/kg/min; divide by 3.5 for estimated METs.
- 2026 AHA/ACC perioperative guideline — reaffirmation ↗. DASI ≤34 is a guideline threshold; interpretation depends on the clinical context. Overall cardiac risk considers both patient and procedural factors.
- Wijeysundera et al., 2026 — pooled DASI cohort study ↗. Interpret DASI continuously alongside clinical risk; a threshold alone does not determine further testing or readiness.
For focused explanations, see the RCRI, ARISCAT, and DASI calculators.
Educational use only. This tool and its outputs do not constitute medical advice, diagnosis, or treatment and do not replace clinical judgment. Independently verify the inputs, equations, assumptions, units, and outputs, and confirm that the tool is appropriate for your intended use before relying on a result.