What preoperative testing is necessary for a patient with a history of CAD, prior PCI and CABG, undergoing bilateral total knee replacements?

Preoperative Testing for Bilateral Total Knee Replacements in a Patient with Complex CAD History

For a patient with complex coronary artery disease history undergoing bilateral total knee replacements, a preoperative 12-lead ECG and clinical risk assessment are recommended, but routine additional cardiac testing is not necessary unless there are new cardiac symptoms or clinical deterioration. 1

Assessment of Cardiac Risk

This patient has a complex cardiac history including:

• Multiple PCIs to the RCA (2011)
• CABG x2 (2011) with SVG to OM and PDA
• Most recent cardiac catheterization (2021) showing:
  • Mild ISR of proximal RCA stents without obstructive disease
  • CTO of PDA with occluded SVG
  • Moderate diffuse disease of LAD (30% mid) and Cx (50% proximal)
  • Patent SVG to OM

Required Preoperative Testing

1. Preoperative 12-lead ECG

   • Recommended for patients with known coronary heart disease undergoing intermediate-risk procedures like orthopedic surgery 1
   • Serves as an important baseline for comparison if postoperative complications develop

2. Clinical Assessment of Functional Status

   • Evaluate exercise capacity (ability to climb stairs, perform daily activities)
   • Assess for any new or changed cardiac symptoms (angina, dyspnea, etc.)

3. Basic Laboratory Tests

   • Complete blood count
   • Basic metabolic panel
   • Coagulation studies

What Testing is NOT Routinely Needed

1. Left Ventricular Function Assessment

   • Not recommended in asymptomatic and clinically stable patients 1
   • Only indicated if the patient has new dyspnea, physical examination findings of heart failure, or suspected new/worsening ventricular dysfunction

2. Stress Testing

   • Not routinely indicated since:
     • Patient had cardiac catheterization in 2021 showing no major progression since 2019
     • No evidence of high-grade obstructive lesions that would benefit from intervention
     • Orthopedic surgery is considered intermediate-risk surgery

3. Coronary Revascularization

   • Routine prophylactic coronary revascularization before noncardiac surgery is not recommended in patients with stable CAD 1
   • The patient's most recent catheterization (2021) showed stable findings compared to 2019

Special Considerations

1. Antiplatelet Management

   • If the patient is on antiplatelet therapy, management should be discussed with the surgical team
   • For patients with coronary stents, aspirin should be continued if possible 1

2. Perioperative Beta-Blockade

   • Consider continuing beta-blockers if the patient is already on them
   • Not recommended to start beta-blockers acutely before surgery 1

3. Medication Reconciliation

   • Review and optimize all cardiac medications
   • Ensure statins are continued through the perioperative period

When Additional Testing Should Be Considered

Additional cardiac testing would be warranted only if:

• New or worsening cardiac symptoms (chest pain, dyspnea, etc.)
• Decreased functional capacity since last evaluation
• Clinical evidence of heart failure
• Significant arrhythmias

Follow-up Recommendations

1. Postoperative Monitoring

   • Continuous telemetry for at least 24-48 hours given the complex cardiac history
   • Daily ECGs for the first 48-72 hours

2. Early Mobilization

   • Encourage early mobilization to reduce thrombotic risk

3. Optimization of Secondary Prevention

   • Ensure continuation of appropriate medical therapy for CAD
   • Consider cardiology follow-up within 1-3 months after surgery

This approach focuses on clinical assessment and basic testing while avoiding unnecessary advanced cardiac testing that would not change management in this clinically stable patient with known, recently evaluated CAD.