What information should be included in a pre‑operative clearance note from the primary care physician?

Preoperative Clearance Note: Essential Components

A preoperative clearance note from a primary care physician must include a comprehensive cardiovascular risk assessment, functional capacity evaluation, documentation of active cardiac conditions, current medications with specific attention to anticoagulants and cardiac drugs, and a clear statement of perioperative recommendations—but should never use the phrase "cleared for surgery." 1, 2, 3, 4

Critical History Elements

Your preoperative note must identify active cardiac conditions that require evaluation and treatment before proceeding 1, 2, 3:

• Unstable coronary syndromes: Unstable or severe angina (CCS class III or IV), or recent MI (within 30 days)
• Decompensated heart failure: NYHA class IV, worsening or new-onset heart failure
• Significant arrhythmias: High-grade AV block, Mobitz II, third-degree heart block, symptomatic ventricular arrhythmias, uncontrolled atrial fibrillation (HR >100 bpm at rest), symptomatic bradycardia, or newly recognized ventricular tachycardia
• Severe valvular disease: Severe aortic stenosis (mean gradient >40 mmHg, valve area <1.0 cm², or symptomatic) or symptomatic mitral stenosis

Document the following additional cardiac history 1, 2, 3, 4:

• Prior angina or MI history
• Presence of pacemaker or ICD
• History of orthostatic intolerance
• Coronary risk factors: diabetes, hypertension, hyperlipidemia, smoking, family history

Functional Capacity Assessment

Quantify functional capacity in metabolic equivalents (METs) 1, 2:

• <4 METs (poor): Cannot walk 2 blocks on level ground or climb 1 flight of stairs
• 4-10 METs (moderate): Can climb stairs, walk uphill, run short distances, do heavy housework
• >10 METs (excellent): Can participate in strenuous sports

Patients with moderate to good functional capacity (>4 METs) can generally proceed to surgery even with clinical risk factors, while those with poor functional capacity require further risk stratification 1, 5.

Physical Examination Findings

Document a focused cardiovascular and pulmonary examination 1, 6:

• Vital signs (including heart rate and blood pressure)
• Airway assessment (critical for anesthesia planning)
• Cardiac examination: presence of S3 gallop, murmurs suggesting valvular disease
• Pulmonary examination: bilateral rales suggesting heart failure, wheezing
• Signs of volume overload or decompensation

Comorbid Conditions

Identify and document optimization status of 1, 2, 4:

• Diabetes mellitus: Particularly if insulin-requiring
• Renal dysfunction: Creatinine >2 mg/dL or creatinine clearance <60 mL/min
• Cerebrovascular disease: Prior stroke or TIA
• Peripheral vascular disease
• Chronic pulmonary disease: COPD, asthma control status
• Liver disease

Medication Documentation

List all current medications with specific attention to 1, 2, 3:

• Beta-blockers: Document continuation plan
• ACE inhibitors/ARBs: Consider holding morning of surgery due to intraoperative hypotension risk 4
• Antiplatelet agents: Aspirin, clopidogrel—critical for timing if recent stent placement
• Anticoagulants: Warfarin, DOACs—bridging strategy needed
• Insulin and oral hypoglycemics: Perioperative management plan
• Herbal supplements and over-the-counter medications
• Alcohol, tobacco, and illicit drug use

Critical Timing for Antiplatelet Therapy

If patient has coronary stents 5:

• Balloon angioplasty: Can proceed after 2 weeks with aspirin continuation
• Bare metal stent: Wait 6 weeks to 3 months; continue dual antiplatelet therapy for at least 6 weeks
• Drug-eluting stent: Wait 12 months; continue dual antiplatelet therapy throughout

Surgical Risk Stratification

Document the planned surgical procedure and its cardiac risk 1, 5:

• Low risk (<1%): Endoscopy, superficial procedures, cataract surgery, breast surgery
• Intermediate risk (1-5%): Intraperitoneal, intrathoracic, orthopedic, prostate surgery
• High risk (>5%): Vascular surgery, prolonged procedures with large fluid shifts

Laboratory and Testing Results

Include only tests that will change management 1, 4, 6:

• Recent ECG (if cardiac risk factors present or age >50)
• Echocardiogram results (if heart failure symptoms or valvular disease suspected)
• Stress test results (if performed for risk stratification)
• Recent laboratory values: CBC, electrolytes, creatinine, glucose, coagulation studies (only if clinically indicated)
• Chest X-ray (only if cardiopulmonary symptoms)

Avoid routine testing in asymptomatic patients undergoing low-risk procedures 6.

Special Populations

For transgender and gender-diverse patients 7:

• Confirm preferred name and pronouns
• Document hormone therapy and plan for continuation (generally continue throughout perioperative period unless contraindicated)
• Note any gender-affirming surgical procedures, particularly facial/neck procedures affecting airway assessment
• Document if cricothyroid approximation performed (standard emergency airway may not be possible)
• Note if chest binders used (should be removed before anesthesia)

Specific Recommendations Section

Your note must include clear, actionable recommendations 1, 2, 4:

DO Include:

• Specific perioperative medication management (continue, hold, adjust doses)
• Need for additional cardiac testing or cardiology consultation
• Recommended level of postoperative monitoring (floor vs. ICU)
• Optimization strategies needed before surgery
• Estimated perioperative cardiac risk based on clinical risk factors and functional capacity
• Long-term cardiac risk and recommendations for follow-up

DO NOT Include:

• Never write "cleared for surgery" or "okay for surgery" 1, 2, 4—this oversimplifies complex risk assessment and shifts inappropriate liability

Instead, state: "Patient's cardiovascular status has been evaluated. Estimated perioperative cardiac risk is [low/intermediate/high] based on [specific factors]. Recommend [specific interventions]. Patient is optimized for the planned procedure with the understanding that [specific risks] exist."

Communication Requirements

Ensure direct communication with the surgical and anesthesia teams 1, 8, 4:

• Discuss any unstable conditions requiring delay
• Alert anesthesia to difficult airway concerns, need for special monitoring, or contraindications to specific agents
• Coordinate timing if additional cardiac interventions needed
• Document that discussion occurred

Common Pitfalls to Avoid

1. Don't delay surgery for unnecessary testing: Only order tests that will change management 1, 4, 6
2. Don't recommend prophylactic coronary revascularization: This does not reduce perioperative risk in stable patients 5
3. Don't stop beta-blockers abruptly: Continue in patients already taking them 3, 4
4. Don't forget to verify fasting status: Document patient education about NPO requirements 9
5. Don't ignore functional capacity: This is often more predictive than testing 1

Documentation of Optimization

State whether the patient is in optimal medical condition within the context of their surgical illness 1, 2:

• Heart failure: Euvolemic, on appropriate diuretics and ACE inhibitors
• Hypertension: Blood pressure controlled (though mild hypertension is not a reason to delay)
• Diabetes: Glucose reasonably controlled
• COPD: On appropriate bronchodilators, no active exacerbation
• Anticoagulation: Appropriate bridging plan in place

The preoperative evaluation is an opportunity to improve long-term cardiovascular health—document recommendations for post-surgical follow-up and risk factor modification 1, 4.