What is the risk stratification for a 79-year-old female with stable Chronic Obstructive Pulmonary Disease (COPD), well-controlled Hypertension (HTN), and Type 2 Diabetes Mellitus (DM) status post left carotid endarterectomy undergoing cataract surgery?

From the Guidelines

This patient is at moderate risk for perioperative complications during cataract surgery due to her age and comorbidities, including stable Chronic Obstructive Pulmonary Disease (COPD), well-controlled Hypertension (HTN), and Type 2 Diabetes Mellitus (DM) status post left carotid endarterectomy. The procedure itself is low-risk, but her age and comorbidities increase her overall risk profile. She should continue her antihypertensive medications through the perioperative period, including the morning of surgery, as recommended by the 2014 ESC/ESA guidelines on non-cardiac surgery 1. Her diabetes medications should be adjusted on the day of surgery, typically holding oral hypoglycemics the morning of surgery while monitoring blood glucose levels. For her COPD, she should continue using her maintenance inhalers (such as tiotropium or fluticasone/salmeterol) as prescribed, including the morning of surgery, to minimize post-operative respiratory complications. Given her history of carotid endarterectomy, if she is on antiplatelet therapy such as aspirin (81mg daily), this should be continued perioperatively as the bleeding risk during cataract surgery is minimal compared to the risk of thrombotic events if discontinued, as suggested by the 2011 ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS guideline on the management of patients with extracranial carotid and vertebral artery disease 1. However, if she is on stronger antiplatelet agents like clopidogrel or anticoagulants like warfarin, a discussion between the ophthalmologist and her primary physician is warranted to determine appropriate management. Preoperative optimization should include ensuring her COPD is stable with no recent exacerbations, her blood pressure is well-controlled (ideally below 140/90 mmHg), and her diabetes is well-managed with HbA1c preferably below 8%, as recommended by the 2006 American College of Physicians guideline on risk assessment for and strategies to reduce perioperative pulmonary complications for patients undergoing noncardiothoracic surgery 1. This risk stratification balances her chronic conditions against the relatively minimal physiological stress of cataract surgery, which typically uses local anesthesia and has minimal hemodynamic effects. Key considerations include:

• Age as a significant predictor of postoperative pulmonary complications, with an odds ratio of 2.09 (95% CI, 1.70 to 2.58) for patients 60 to 69 years of age and 3.04 (CI, 2.11 to 4.39) for those 70 to 79 years of age compared with younger patients 1.
• Chronic obstructive pulmonary disease as the most commonly identified risk factor for postoperative pulmonary complications, with an odds ratio of 1.79 (CI, 1.44 to 2.22) 1.
• The importance of functional dependence as a predictor of postoperative pulmonary complications, with an odds ratio of 2.51 (CI, 1.99 to 3.15) for total dependence and 1.65 (CI, 1.36 to 2.01) for partial dependence 1.

From the Research

Risk Stratification for Cataract Surgery

The patient in question is a 79-year-old female with a medical history of stable Chronic Obstructive Pulmonary Disease (COPD), well-controlled Hypertension (HTN), and Type 2 Diabetes Mellitus (DM), who has undergone a left carotid endarterectomy. To determine the risk stratification for cataract surgery in this patient, several factors need to be considered:

• Cardiovascular Risk: According to 2, the Revised Cardiac Risk Index can be used to identify and risk-stratify intermediate-risk preoperative patients. Given the patient's history of carotid endarterectomy and well-controlled hypertension, her cardiovascular risk needs to be carefully evaluated.
• COPD and Beta-Blockers: Studies such as 3 and 4 suggest that beta-blockers can be used in patients with COPD, especially if they have a clear cardiovascular indication. However, caution is advised, and the patient's lung function should be closely monitored.
• Diabetes Mellitus: As indicated by 3, beta-blockers are not contraindicated in patients with diabetes mellitus, but caution should be exercised, especially if there are signs of autonomic disease or difficult glycemic control.
• Surgical Risk: The patient's overall surgical risk can be estimated using preoperative risk assessment tools, as discussed in 5. Factors such as the patient's ASA physical status score, the urgency of the surgery, and potential intraoperative complications should be taken into account.

Key Considerations

• The patient's stable COPD and well-controlled hypertension suggest that she can undergo cataract surgery with careful monitoring and management of her conditions.
• The use of beta-blockers should be carefully considered, given the patient's COPD and diabetes mellitus.
• A thorough preoperative evaluation, including assessment of the patient's cardiovascular risk and overall surgical risk, is essential to identify potential complications and develop strategies to mitigate them.

Risk Stratification Factors

• Age: 79 years
• Medical history: stable COPD, well-controlled hypertension, Type 2 diabetes mellitus, left carotid endarterectomy
• Surgical procedure: cataract surgery
• Potential risks: cardiovascular complications, respiratory complications, surgical complications
• Management strategies: careful monitoring of lung function, optimization of medical therapy, including beta-blockers if indicated, and close surveillance for potential complications during and after surgery, as suggested by 6.