Over the past several decades, the field of preoperative cardiac evaluation before noncardiac surgery has evolved substantially. Initially, the focus was on identifying high-risk patients who might benefit from additional interventions, but the value of those interventions, such as coronary revascularization, was unknown. Beginning around the time of the publication of the first American College of Cardiology/American Heart Association (ACC/AHA) Guidelines in 1996, the focus has evolved from identification of risk to targeted evaluation and treatment for those in whom it would impact outcome, ie, those in whom there is clearly value.

There are currently 3 major Society Guidelines, the 2014 ACC/AHA Guidelines,¹ the 2014 European Society of Cardiology/European Society of Anesthesiology,² and the 2017 Canadian Cardiovascular Society (CCS),³ that address preoperative assessment. There are clear differences between the first 2 guidelines and the more recent CCS Guidelines, which may, in part, reflect the evolution of new evidence since the publication of earlier guidelines. However, a notable philosophical difference in data interpretation is clear as well.

Until recently, the ACC/AHA Guidelines, and most medical consultations, included the assumption that surgery was not only indicated but would occur. As health care moves from volume to value, shared decision making around the risks and benefits of surgery …

在过去的几十年中，非心脏手术前的术前心脏评估领域已经发生了很大的变化。最初，重点是确定可能从其他干预措施中受益的高风险患者，但这些干预措施（例如冠状动脉血运重建）的价值尚不明确。从1996年第一本美国心脏病学会/美国心脏协会（ACC / AHA）指南发布开始，关注的重点已经从识别风险转变为针对可能影响结果的人群进行有针对性的评估和治疗，即，那些显然具有价值的人。

目前，有3项主要的社会指南，即2014年ACC / AHA指南，^1项2014年欧洲心脏病学会/欧洲麻醉学会，^2项和2017年加拿大心血管学会（CCS），其中^3项涉及术前评估。前两个指南与较新的CCS指南之间存在明显的差异，这可能部分反映了自较早的指南发布以来新证据的演变。但是，在数据解释方面也存在明显的哲学差异。

直到最近，ACC / AHA指南以及大多数医学咨询都包括这样一种假设，即不仅要进行手术，而且还会进行手术。随着医疗保健从数量到价值的转变，围绕手术风险和利益的共同决策……