A 56-year-old patient presents with decompensated heart failure and ongoing chest pain requiring noncardiac surgery. Which ASA class applies?

• A. ASA III
• B. ASA IV
• C. ASA II
• D. ASA V

Answer: (B)

The patient’s decompensated heart failure along with ongoing chest pain indicates unstable, life-threatening cardiovascular disease. ASA classification reflects the overall preoperative health and the risk the systemic disease poses; when the disease is severe and poses a constant threat to life, that fits ASA IV. The scenario shows active instability and risk of deterioration, which is more serious than the limitations seen in ASA III and far from the moribund state described by ASA V. If this were an emergency situation requiring immediate operation due to instability, an emergency modifier would apply, but without that explicit status the appropriate label is ASA IV.