What are the preoperative cardiovascular management recommendations for a 66-year-old male with hypertension (HTN), hyperlipidemia, and chronic back pain, who is a current smoker and scheduled for lumbar fusion surgery?

Preoperative Cardiovascular Management for a 66-Year-Old Male Undergoing Lumbar Fusion

For this 66-year-old male with hypertension, hyperlipidemia, and exertional chest pain, he should proceed with surgery as his stress echocardiogram was negative, but his cardiovascular medications (losartan/HCTZ and ezetimibe) should be continued perioperatively with a target LDL of <70 mg/dL.

Risk Assessment

This patient has several cardiovascular risk factors that require careful consideration before lumbar fusion surgery:

• 66 years of age (increased risk)
• Male gender (higher risk than females)
• Current smoker (significant modifiable risk factor)
• Hypertension (148/88 mmHg, not optimally controlled)
• Hyperlipidemia (LDL 116 mg/dL, above target)
• Exertional chest pain (concerning symptom)
• LVH on EKG (end-organ damage)
• Lumbar fusion (intermediate-high risk procedure)

Risk Stratification

The patient's risk for perioperative cardiovascular complications is elevated based on:

1. Multiple risk factors from the Revised Cardiac Risk Index 1
2. Lumbar fusion is considered an intermediate-high risk procedure with significant fluid shifts and hemodynamic changes 2
3. Male sex increases cardiac risk (OR = 1.51) for adverse cardiac events after lumbar fusion 3
4. Current smoking status increases risk (OR = 1.39) 3

Preoperative Testing

The negative exercise stress echocardiogram is reassuring and indicates:

• Adequate exercise capacity
• No evidence of inducible ischemia
• No echocardiographic evidence of significant cardiac dysfunction

This negative test is appropriate given the patient's risk profile and symptoms. According to the 2024 AHA/ACC guidelines, patients with exertional chest pain should undergo appropriate cardiac testing before intermediate-high risk procedures 2.

Medication Management

Antihypertensive Therapy

• Continue losartan/HCTZ perioperatively - The 2024 AHA/ACC guidelines recommend continuing antihypertensive medications throughout the perioperative period (Class 2a, Level C-EO) 2
• Monitor blood pressure closely during the perioperative period
• Target intraoperative MAP ≥60-65 mmHg or SBP ≥90 mmHg to reduce risk of myocardial injury (Class 1, Level B-NR) 2
• Restart antihypertensive medications as soon as clinically reasonable postoperatively (Class 1, Level C-EO) 2

Lipid Management

• Continue ezetimibe to achieve target LDL <70 mg/dL for this high-risk patient
• Consider more aggressive lipid-lowering therapy if target not achieved
• Perioperative continuation of lipid-lowering therapy is recommended (Class 1, Level B) 2

Perioperative Cardiovascular Risk Reduction

1. Smoking cessation should be strongly encouraged as it significantly increases perioperative cardiac risk 3

2. Blood pressure control is essential:

   • Continue antihypertensive medications
   • Target BP <140/90 mmHg preoperatively
   • Avoid intraoperative hypotension (MAP <60-65 mmHg) 2

3. Consider perioperative beta-blockade:

   • For high-risk patients undergoing intermediate-high risk surgery, beta-blockers may be considered (Class IIb, Level A) 2
   • However, initiation should be done cautiously and well before surgery to avoid hypotension

Monitoring Recommendations

1. Standard ASA monitoring intraoperatively
2. Consider postoperative cardiac biomarker monitoring given the patient's risk profile
3. Monitor for signs/symptoms of cardiac events in the postoperative period

Potential Complications

Patients undergoing lumbar fusion have a cardiac event rate of approximately 4.76 events per 1000 patients 3. The mortality rate for those sustaining a cardiac event is significantly higher (24.6%) compared to those without (0.2%) 3.

Follow-up Plan

1. Reassess cardiovascular status after surgery
2. Continue optimization of cardiovascular risk factors
3. Maintain target LDL <70 mg/dL and BP <140/90 mmHg

The patient's negative stress echocardiogram is reassuring, but ongoing cardiovascular risk factor modification remains essential for long-term outcomes.