Is a 71-year-old female with complete heart block, pacemaker, hypertension, acidemia, diabetes, obesity, and reduced left ventricular function cleared for cataract surgery or does she need a stress test?

Perioperative Cardiac Clearance for Cataract Surgery in a Patient with Multiple Cardiac Comorbidities

The patient can proceed to cataract surgery without a stress test, as cataract surgery is considered a very low-risk procedure with minimal cardiac risk regardless of the patient's cardiac comorbidities.

Risk Assessment for Cataract Surgery

Surgical Risk Classification

• Cataract surgery is classified as a very low-risk procedure (ophthalmologic surgery) with cardiac risk <1% 1
• According to the ACC/AHA guidelines, even patients with multiple risk factors undergoing very low-risk surgery have a low risk of Major Adverse Cardiac Events (MACE) 1

Patient-Specific Risk Factors

This patient has multiple cardiac risk factors:

• Complete heart block with pacemaker (with pacemaker-mediated tachycardia)
• Reduced left ventricular function (45-50%)
• Diastolic relaxation pattern
• Hypertension
• Diabetes
• Obesity
• Recent episode of dyspnea

Guideline-Based Decision Algorithm

Following the ACC/AHA perioperative evaluation algorithm 1:

1. Step 1: Determine urgency of surgery - elective cataract surgery
2. Step 3: Patient has risk factors for stable CAD - estimate perioperative risk
3. Step 4: For very low-risk surgery (ophthalmologic surgery), even with multiple risk factors, the risk of MACE is <1%
4. Step 4 conclusion: No further testing is needed, and the patient may proceed to surgery

Supporting Evidence

The 2014 ACC/AHA guidelines specifically state: "A patient undergoing very low-risk surgery (eg, ophthalmologic surgery), even with multiple risk factors, would have a low risk of MACE" 1.

The 2024 updated AHA/ACC guidelines maintain this position, stating: "In patients who are at low risk for perioperative cardiovascular events, have adequate functional capacity with stable symptoms, or who are undergoing low-risk procedures, routine stress testing before NCS is not recommended due to lack of benefit" 1.

Considerations for Specific Cardiac Issues

Pacemaker Management

• The pacemaker-mediated tachycardia (PMT) should be addressed and optimized before surgery
• A preoperative ECG is reasonable given the patient's cardiac history 1
• Ensure appropriate pacemaker interrogation and management before surgery

Left Ventricular Dysfunction

• While the patient has reduced LV function (45-50%), routine preoperative evaluation of LV function is not recommended 1
• The diastolic relaxation pattern does not change the recommendation for this very low-risk procedure

Potential Pitfalls to Avoid

1. Overtesting: Stress testing in patients undergoing low-risk procedures does not improve outcomes and may lead to unnecessary delays, costs, and potential harm 2

2. Misclassification of risk: Despite multiple comorbidities, the very low-risk nature of cataract surgery is the primary determinant of perioperative cardiac risk

3. Ignoring pacemaker issues: While stress testing is not needed, the PMT should be addressed before surgery to optimize cardiac function

Summary of Recommendations

• Proceed with cataract surgery without stress testing
• Ensure pacemaker optimization before surgery
• Consider preoperative ECG given cardiac history
• No additional cardiac testing is indicated based on current guidelines

This approach aligns with evidence showing that cataract surgery has exceptionally low rates of postprocedural cardiovascular events, and preprocedural cardiovascular testing rarely impacts outcomes 2.