Before a planned operation, the pre-operative assessment helps decide what happens in the operating theatre and in the hours that follow. In a careful internal-medicine and cardiology review, we identify risks before they turn into complications and give the anaesthetist the information they need for a safe anaesthetic. At the DTL practice we bundle this preparation under one roof and evaluate any abnormal findings together with our cardiology co-lead.
What pre-operative assessment delivers
Why preparation shapes the outcome
Perioperative cardiovascular events are the most common cause of death and complications after non-cardiac surgery. A US analysis of more than ten million inpatient procedures in patients aged 45 and over found a perioperative MACCE incidence (death, myocardial infarction and stroke combined) of around 3 percent, with markedly higher risk in vascular, thoracic and major abdominal surgery [Smilowitz NR et al., JAMA Cardiol 2017]. The 2022 ESC guideline stresses that systematic preparation cannot eliminate these events. It can, however, influence them meaningfully through early identification and targeted optimisation [Halvorsen S et al., Eur Heart J 2022].
Three factors determine the risk:
- Patient factors. Age, comorbidities (coronary heart disease, heart failure, diabetes, renal impairment, COPD), regular medication, physical fitness. The Revised Cardiac Risk Index (RCRI) and the ASA classification [ASA Physical Status Classification System] are the standard tools.
- Procedure-specific risks. The ESC guideline distinguishes low (<1 percent cardiac risk), intermediate (1-5 percent) and high (>5 percent) surgical risk. Cataract surgery belongs in the first category, open aortic surgery in the last [Halvorsen S et al., Eur Heart J 2022].
- Functional capacity. Anyone who can climb two flights of stairs without symptoms reaches about 4 MET and, according to the ESC, is fit enough for most procedures. At <4 MET or with unclear fitness, the cardiac work-up is stepped up [Halvorsen S et al., Eur Heart J 2022].
Combining these three factors, we determine whether a resting ECG is sufficient or whether echocardiography, exercise testing or further imaging is indicated.
What we actually examine at Dein Team
In the internal-medicine preparation we work through five areas. What is examined depends on the surgical risk, your age and your previous illnesses. No routine test without an indication.
- History and clinical examination. Previous illnesses, previous operations, allergies, medication list, family history, fitness in MET. Auscultation of heart and lungs, peripheral pulse pattern, blood pressure in both arms, a basic neurological check.
- Laboratory tests. For intermediate and high surgical risk: full blood count, electrolytes, creatinine and estimated glomerular filtration rate, glucose and HbA1c in diabetes, coagulation parameters, liver values. The 2022 ESC guideline recommends NT-proBNP in patients >65 years or with a cardiovascular risk profile before intermediate- or high-risk surgery [Halvorsen S et al., Eur Heart J 2022].
- Resting ECG. Standard for all patients with a cardiovascular history and for intermediate to high surgical risk. It detects rhythm disorders, bundle branch block and signs of ischaemia, and it provides the baseline for the post-operative ECG.
- Imaging where indicated. Transthoracic echocardiography for known or suspected heart failure, valve disease or new dyspnoea. Exercise testing (ergometry, stress echo, stress MRI) at <4 MET before high-risk surgery [Halvorsen S et al., Eur Heart J 2022]. Lung function testing (spirometry) for known COPD, persistent cough or before thoracic surgery.
- Risk stratification. RCRI, ASA status, ESC algorithm. The scores appear in the report in translated form, related to your operation and to the anaesthetic, rather than as a raw number without context.
The findings go straight to surgeon and anaesthetist in a structured report. Instead of three or four separate appointments with the GP, cardiology and the laboratory, the work-up takes place in a single consultation. No duplicate appointments.
Pre-operative assessment · every examination under one roof
History, ECG, laboratory tests and imaging in a single consultation. Structured report to surgeon and anaesthetist within 48 hours.
View serviceMedication management before the procedure
Here lies one of the most common causes of avoidable complications. Which medicines you take on the day of surgery, which you pause and whether bridging is needed should never be an improvised decision the evening before. Three groups of drugs demand particular attention:
Anticoagulants and antiplatelet agents. For patients with atrial fibrillation on vitamin K antagonists, the 2015 BRIDGE trial is the reference: in patients at moderately high stroke risk, a perioperative pause of anticoagulation without bridging was no worse than bridging with low-molecular-weight heparin, and it reduced the bleeding risk markedly [Douketis JD et al., NEJM 2015]. For direct oral anticoagulants (DOACs), the ESC guideline specifies procedure-dependent pause intervals, as a rule 24 to 48 hours before low to intermediate bleeding risk and 48 to 72 hours before high bleeding risk, depending on kidney function [Halvorsen S et al., Eur Heart J 2022]. Aspirin is continued before most procedures; clopidogrel and prasugrel are usually paused for elective surgery. The individual response to antiplatelet agents also depends on CYP2C19 status, which we take into account at the DTL practice (we cover this in a separate article on antiplatelet agents and individual response).
Diabetes medication. Metformin is paused on the day of surgery, SGLT2 inhibitors (empagliflozin, dapagliflozin, canagliflozin) ideally three to four days before the procedure because of the risk of euglycaemic ketoacidosis [Halvorsen S et al., Eur Heart J 2022]. Insulin is adjusted rather than omitted. HbA1c values above 8.5 percent often call for optimisation before elective surgery.
Antihypertensives. Beta-blockers taken long term are never stopped abruptly. ACE inhibitors and AT1 antagonists are continued in stable heart failure, though they are frequently paused on the day of surgery to avoid intra-operative hypotension that is harder to treat [Halvorsen S et al., Eur Heart J 2022].
Which perioperative blood pressure strategy is better was an open question for a long time. The POISE-3 substudy (7,490 patients, 22 countries) compared a hypotension-avoidance strategy with a hypertension-avoidance strategy and found no difference in the combined endpoint of death, myocardial injury, stroke and cardiac arrest within 30 days, which stood at 14 percent in both arms [Marcucci M et al., Ann Intern Med 2023]. The clinical consequence: the decision about which antihypertensives are given or paused on the day of surgery remains individual and begins with the pre-operative assessment.
Pre-operative cardiovascular evaluation is guided by the surgical risk and by functional capacity rather than by a fixed testing routine. Routine tests without an indication delay the procedure and rarely provide clinically relevant information.
Co-leadership with cardiology · when Gloekler joins
The internal-medicine work-up covers the spectrum for most elective procedures. In three situations we bring in the cardiology co-lead, Prof. Dr. Steffen Gloekler:
- Abnormal finding. New signs of ischaemia on the ECG, newly occurring bundle branch block, pathological NT-proBNP, newly detected atrial fibrillation, a heart murmur without a known cause. The cardiology assessment usually takes place within the same week, with echocardiography and, if needed, exercise testing.
- High surgical risk in patients with a cardiovascular history. For planned vascular, thoracic or major abdominal surgery with ≥2 RCRI risk factors, the ESC recommends a specialist pre-assessment [Halvorsen S et al., Eur Heart J 2022].
- Patients with stents and antithrombotic therapy. In patients with a recent coronary intervention, the timing of dual antiplatelet therapy is a topic in its own right. Here the cardiology assessment decides, often in consultation with the implanting centre.
The findings pass directly between the two practices, without you having to forward the report yourself.
When to book the pre-operative assessment
Ideally three to four weeks before the planned procedure. Enough time to optimise diabetes control, adjust antihypertensive therapy or complete a cardiology work-up. For low-risk procedures one week is often enough; for high-risk procedures we recommend four to six weeks' lead time.
What to bring to the appointment:
- The exact diagnosis and the planned date of surgery
- Your current medication list (with doses and times of intake)
- Previous findings from the last twelve months (hospital reports, cardiology findings, laboratory results)
- Your insurance card and personal details
Billing goes through compulsory health insurance under TARDOC, the Swiss outpatient tariff. With supplementary insurance, extended optional services are possible. Reception clarifies the billing and, for international patients, sends the invoice directly.
Where to read on in the cluster
Pre-operative preparation touches on several internal-medicine and cardiology topics. Related topics we cover in the DTL knowledge section:
- Executive Health Check. A structured review of your health without an operation ahead.
- High blood pressure · When to see a cardiologist. When blood pressure control is not stable before the procedure.
- Antiplatelet agents and individual response. What CYP2C19 status means for perioperative management.
- Polypharmacy review. When five or more regular medicines need to be coordinated perioperatively.
The cardiology side of pre-operative risk stratification sits with the sister hub: Cardiac risk stratification before surgery on dth.healthcare.
Frequently asked questions
How much lead time do I need for the pre-operative assessment?
Do I have to stop my aspirin before the operation?
As a rule, no. Aspirin is continued for most procedures because the cardiovascular risk of a pause usually outweighs the bleeding risk. Exceptions are neurosurgical and certain ophthalmological procedures. The individual decision is made in the pre-operative consultation, in agreement with the surgeon [Halvorsen S et al., Eur Heart J 2022].
Do I need bridging if I take Marcoumar?
For most patients with atrial fibrillation and a moderately high stroke risk, no. The BRIDGE trial showed that a pause without heparin bridging is no worse and is safer [Douketis JD et al., NEJM 2015]. This does not apply to mechanical heart valves or a very high thromboembolic risk. The GP and the cardiologist make that decision together.
What if my operation is in two weeks and I have not had an assessment yet?
We will fit you in. Appointment usually within a week. The work-up is tailored to the time available, with a clear recommendation for the surgeon and the anaesthetist.
Does health insurance cover the pre-operative assessment?
Yes, given a medical indication. Outpatient medical services are mandatory benefits under compulsory basic insurance and are billed under TARDOC. Your share of the costs is governed by your policy.
Who receives the report?
The structured report goes directly to the surgeon and the anaesthetist, with a copy to your GP if they are not part of our practice. You receive a plain-language summary for yourself.
Pre-operative consultation at Dein Team fürs Leben
Appointment usually within a week, ideally three to four weeks before the planned procedure. Medical interview, ECG, laboratory tests and imaging under one roof. If you develop acute symptoms before the procedure (chest pressure, shortness of breath, fainting), dial 144.
Book an appointmentAuthor: Prof. Dr. C.K. Fritz M.Sc., Physician Associate for General Internal Medicine, Pain Medicine, Practice Lead Dein Team fürs Leben, Zürich.
