ÖGARI pre-operative cardiac work-up (Austrian guideline 2026)
ECG, echocardiography and cardiac biomarkers before elective non-cardiac surgery by METs, surgical category and symptoms
- ÖGARI guideline pre-operative evaluation 2026
- ESC 2022 non-cardiac surgery guideline
Sources last checked: 2026-10-13
ÖGARI pre-operative cardiac work-up (Austrian guideline 2026)
ECG, echocardiography and cardiac biomarkers before elective non-cardiac surgery by METs, surgical category and symptoms
For adults before elective non-cardiac surgery. The NT-proBNP threshold for omitting TTE is printed as '300 mg/L' in the figure legend; the usual unit is ng/L (pg/mL). Elevated biomarkers alone are not a reason to postpone surgery (p. 28-29). In Austria, the OP release ('OP-Freigabe') is an anaesthesiological decision; internal-medicine or GP assessments inform organ-specific risk but are not an OP release (p. 36).
Interpretation
| No routine ECG — no further cardiac work-up | ≥ 4 METs, small procedure, no cardiac symptoms: the guideline does not foresee a routine pre-operative 12-lead ECG (2B); Figure 1 continues directly to the anaesthesiological OP release. |
|---|---|
| 12-lead ECG may be considered | ≥ 4 METs, large procedure, asymptomatic without known cardiovascular disease: ECG can be considered (2B); Figure 1 lists ECG on the ≥ 4 METs / large-procedure path. No TTE without symptoms or risk factors (1B). |
| 12-lead ECG indicated | Large procedure with known cardiovascular disease (1B), or cardiac symptoms at any procedure size ('always'). In the guideline, new ECG abnormalities lead to further work-up. |
| 12-lead ECG and transthoracic echocardiography | ≥ 4 METs with suspected new or worsening heart failure or valvular disease: the guideline recommends TTE (1B). According to the guideline, TTE can be omitted if POCUS answers the question, NT-proBNP < 300 or TropT < 14 ng/L, or a TTE ≤ 1 year old exists with stable symptoms. |
| < 4 METs, small procedure — ECG and TTE per Figure 1; no biomarkers | Figure 1 routes < 4 METs to ECG, TTE and NT-proBNP/TropT, but the guideline text says natriuretic peptides and troponin should not be measured before small procedures (p. 28, 1C). Figure 1 then continues with shared decision-making. |
| < 4 METs, large procedure — ECG, TTE, NT-proBNP/troponin, shared decision-making | Figure 1: ECG, TTE and NT-proBNP/TropT (NT-proBNP before large procedures with increased CV risk 1B; troponin 2B), then shared decision-making and advance care planning → OP release, or adapted/no surgery. |
What is the ÖGARI pre-operative cardiac work-up (Austrian guideline 2026)?
This tool follows Figure 1 (extended pre-operative cardiac work-up) and the ECG, echocardiography and biomarker recommendations of the Austrian ÖGARI guideline on pre-operative evaluation of adults, Update 2026. The pathway starts from the history, splits by functional capacity (≥ 4 vs < 4 METs) and surgical category, and ends in the anaesthesiological OP release or, for patients with poor functional capacity, in shared decision-making and advance care planning. Several recommendations were adopted from the 2024 AHA/ACC and 2022 ESC guidelines.
When to use it
- Deciding whether an ECG, TTE or NT-proBNP/troponin is needed before elective non-cardiac surgery.
- Pre-anaesthesia assessment and GP referrals in Austria.
- Reducing unnecessary cardiac testing in fit patients before small procedures.
When not to use it
- Emergency surgery or acute cardiac conditions (acute coronary syndrome, decompensated heart failure) — outside the scope of this pre-operative pathway.
- Cardiac surgery.
- As the sole basis for postponing surgery because of an elevated biomarker.
How it is calculated
History → METs ≥ 4: small → OP release; large → ECG → OP release History → METs < 4: ECG + TTE + NT-proBNP/TropT → shared decision-making → OP release or adapted/no surgery
Clinical pearls and limitations
- For adults before elective non-cardiac surgery. The NT-proBNP threshold for omitting TTE is printed as '300 mg/L' in the figure legend; the usual unit is ng/L (pg/mL). Elevated biomarkers alone are not a reason to postpone surgery (p. 28-29). In Austria, the OP release ('OP-Freigabe') is an anaesthesiological decision; internal-medicine or GP assessments inform organ-specific risk but are not an OP release (p. 36).
- Assess functional capacity in a structured way; the guideline prefers the DASI (or M-DASI) over self-reported METs before large procedures.
- In ÖGARI 2026, cardiac symptoms (chest pain, dyspnoea, palpitations, tachycardia, syncope, murmur) always lead to an ECG.
- TTE is not needed in stable patients without cardiac symptoms or risk factors (1B).
- TTE can be omitted if POCUS answers the question, biomarkers are low, or a recent (≤ 1 year) TTE exists with stable symptoms.
- In Austria, internal-medicine 'clearance' is not an OP release; the anaesthetist decides together with surgeon and patient.
Frequently asked questions
Does every patient over a certain age need a pre-operative ECG?
No. ÖGARI 2026 bases the ECG on surgical category, known cardiovascular disease and symptoms, not on age; for asymptomatic patients before small procedures it does not foresee a routine ECG.
What if a patient cannot climb a flight of stairs?
< 4 METs leads to ECG, TTE and NT-proBNP/troponin (biomarkers only before large procedures), followed by shared decision-making and advance care planning.
Who gives the 'OP-Freigabe' in Austria?
According to the ÖGARI guideline, the OP release is given by the specialist in anaesthesiology after full risk stratification; internal-medicine or GP assessments contribute organ-specific risk evaluation only.
Evidence and guidelines
- Primary source: ARGE präoperatives und tagesklinisches Patientenmanagement der ÖGARI (Duma A et al.). Österreichische Leitlinie zur präoperativen Evaluierung von erwachsenen Patientinnen und Patienten — Update 2026. Figure 1 (Erweiterte präoperative kardiale Abklärung) and legend, p. 35; recommendations pp. 11-15 and 28.
- Halvorsen S et al. 2022 ESC Guidelines on cardiovascular assessment and management of patients undergoing non-cardiac surgery. Eur Heart J 2022;43(39):3826-3924.
- Thompson A et al. 2024 AHA/ACC guideline for perioperative cardiovascular management for noncardiac surgery. Circulation 2024;150(19):e351-e442 (source of the adopted ECG/TTE recommendations).
- Lamperti M et al. ESAIC preoperative assessment guideline. Eur J Anaesthesiol 2025;42(1):1-35.
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Ask Medelix about the ÖGARI pre-operative cardiac work-up (Austrian guideline 2026)Related calculators
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