What is the cardiac risk for a 68-year-old patient with a history of coronary artery disease and prior stents, who has 40% stenosis in one coronary artery, undergoing hemorrhoidectomy under general anesthesia?

Cardiac Risk Assessment for a 68-Year-Old Patient with CAD Undergoing Hemorrhoidectomy

The patient has low cardiac risk for hemorrhoidectomy under general anesthesia due to the non-stenotic nature of the coronary lesion (40% stenosis) and the low-risk nature of the surgical procedure.

Risk Stratification Based on Patient and Surgical Factors

Patient-Specific Risk Factors:

• 68-year-old patient (age is a risk factor)
• History of coronary artery disease with prior stents
• Current 40% stenosis in OM1 (obtuse marginal branch)

Procedure-Related Risk:

• Hemorrhoidectomy is considered a low-risk procedure
• General anesthesia adds minimal additional risk compared to the procedure itself

Analysis of Cardiac Risk

Coronary Anatomy Assessment:

• 40% stenosis is considered non-obstructive coronary disease
• According to CAD-RADS classification, this would be classified as CAD-RADS 2 (25-49% stenosis), indicating mild non-obstructive coronary artery disease 1
• Non-obstructive stenoses (<50%) generally do not cause significant hemodynamic compromise during surgery

Procedural Risk Assessment:

• Hemorrhoidectomy is classified as a low-risk procedure with cardiac complication rates generally <1% 1
• The 2024 AHA/ACC guidelines indicate that patients with stable coronary disease undergoing low-risk procedures have minimal increased perioperative risk 1

Specific Risk Calculation

The patient's risk can be estimated using established risk calculators:

1. Revised Cardiac Risk Index (RCRI) factors present:

   • Coronary artery disease: +1 point
   • Age >65: +1 point
   • Total: 2 points, which corresponds to approximately 1-2% risk of major adverse cardiac events

2. Important considerations:

   • The patient's coronary lesion is non-obstructive (40% stenosis)
   • Prior stents appear to be patent (no mention of in-stent stenosis)
   • No mention of heart failure, diabetes, renal dysfunction, or cerebrovascular disease that would increase risk

Management Recommendations

1. Preoperative testing:

   • No additional stress testing is indicated given the non-obstructive nature of the coronary lesion and low-risk procedure 1
   • Routine ECG is reasonable given the patient's age and cardiac history

2. Medication management:

   • Continue aspirin perioperatively if patient is on it
   • If patient is on dual antiplatelet therapy for recent stent placement, timing of surgery may need adjustment based on stent type and placement date 2
   • Continue statins and beta-blockers if the patient is on them

3. Anesthetic considerations:

   • General anesthesia is appropriate with standard monitoring
   • Consider arterial line if hemodynamic instability is anticipated
   • Maintain hemodynamic stability to avoid tachycardia or hypotension

Common Pitfalls to Avoid

1. Overestimating risk:

   • Avoid unnecessary testing or interventions for non-obstructive disease (40% stenosis) before a low-risk procedure 1
   • The 2024 AHA/ACC guidelines specifically recommend against routine preoperative coronary revascularization for patients with non-left main CAD 1

2. Premature discontinuation of antiplatelet therapy:

   • If the patient has had recent stent placement, premature discontinuation of antiplatelet therapy can lead to stent thrombosis 2
   • Coordinate with cardiology if surgery timing can be adjusted to minimize this risk

3. Underestimating bleeding risk:

   • Hemorrhoidectomy can be associated with postoperative bleeding
   • Balance antiplatelet/anticoagulant management carefully

In summary, this 68-year-old patient with prior coronary stents and current 40% stenosis in OM1 has a low cardiac risk (approximately 1-2%) for hemorrhoidectomy under general anesthesia. The procedure can proceed with standard perioperative cardiac management and monitoring.