What preoperative evaluation and management are recommended for an 88-year-old patient with hypertension, hyperlipidemia, and hyperuricemia, presenting for surgery with a left anterior fascicular block on EKG?

From the Guidelines

For an 88-year-old patient with hypertension, hyperlipidemia, hyperuricemia, and left anterior fascicular block (LAFB) presenting for surgery, a comprehensive preoperative evaluation should include cardiac risk assessment, medication management, and optimization of comorbidities, with a focus on minimizing perioperative cardiovascular complications, as recommended by the most recent guidelines 1. The patient's preoperative evaluation should begin with a thorough history and physical examination, focusing on cardiovascular symptoms, functional capacity, and blood pressure control.

• Laboratory tests should include complete blood count, comprehensive metabolic panel, coagulation studies, and lipid profile.
• The existing LAFB on EKG warrants additional cardiac evaluation, including a 12-lead EKG to assess for any changes and an echocardiogram to evaluate cardiac function and structure.
• Consider cardiology consultation if there are signs of cardiac decompensation or if the patient has poor functional capacity. Hypertension management is crucial, and according to the latest guidelines, hypertension should be well-controlled preoperatively, with continuation of antihypertensive medications through the morning of surgery (except ACE inhibitors and ARBs, which may be held 24 hours before surgery to prevent intraoperative hypotension) 1.
• Statins for hyperlipidemia should be continued perioperatively for their cardioprotective effects.
• For hyperuricemia, allopurinol can generally be continued, but colchicine might be held if there are concerns about drug interactions.
• Assess the patient's volume status and renal function, as elderly patients are susceptible to dehydration and acute kidney injury. Preoperative optimization should include ensuring adequate hydration, optimizing blood pressure control (target <140/90 mmHg), and addressing any electrolyte abnormalities, as supported by previous studies 1. This comprehensive approach addresses the patient's age-related vulnerabilities and specific comorbidities to minimize perioperative cardiovascular complications, in line with the recommendations from the American College of Cardiology and American Heart Association 1.

From the Research

Preoperative Evaluation and Management

The patient's preoperative evaluation and management should focus on assessing and mitigating cardiac risk factors, given their history of hypertension, hyperlipidemia, and hyperuricemia.

• A thorough history and physical examination are essential in detecting most cardiac problems that can affect perioperative management or outcome, as stated in 2.
• The presence of a left anterior fascicular block on EKG should be considered in the context of the patient's overall cardiac risk profile.
• The patient's hyperuricemia should be managed, as it is a cardiovascular and renal risk factor, and treatment options such as xanthine oxidase inhibitors or uricosuric medications may be considered, as discussed in 3.

Cardiac Risk Assessment

• A stepwise approach to perioperative cardiac risk assessment, as set forth by joint American College of Cardiology and American Heart Association guidelines, should be employed, as mentioned in 4.
• The patient's cardiac risk factors, including hypertension, hyperlipidemia, and hyperuricemia, should be taken into account when assessing their overall cardiac risk.
• The use of nonroutine preoperative cardiovascular testing, such as exercise and Holter electrocardiography, radionuclide ventriculography, stress echocardiography, and dipyridamole thallium scintigraphy, may be considered in high-risk patients, as discussed in 5.

Management of Hyperuricemia

• The treatment of asymptomatic hyperuricemia is debated, but recent trials and meta-analysis seem to support this therapeutic strategy, as mentioned in 3.
• The use of febuxostat or allopurinol may be considered for the management of hyperuricemia, as they have been shown to be effective in reducing serum uric acid levels, as discussed in 6.
• The patient's hyperuricemia should be managed in the context of their overall cardiovascular risk profile, and treatment options should be tailored to their individual needs.