What is the best next step in managing a 52-year-old man with hypertension, type 2 diabetes mellitus (T2DM), and heart failure with preserved ejection fraction (HFpEF) who is scheduled for total knee arthroplasty?

Preoperative Cardiac Risk Assessment for Total Knee Arthroplasty

Based on the available evidence, the best next step for this 52-year-old man with hypertension, T2DM, and HFpEF scheduled for total knee arthroplasty is to assess exercise capacity (Option D).

Rationale for Assessing Exercise Capacity

The patient has several cardiac risk factors and a Revised Cardiac Risk Index (RCRI) score indicating a 6% 30-day risk of cardiovascular events, which is considered elevated. In patients with heart failure, particularly HFpEF, exercise capacity assessment provides crucial information about:

1. Functional cardiac reserve
2. Ability to tolerate the hemodynamic stress of surgery
3. Risk stratification beyond what the RCRI score alone provides

Clinical Considerations

• Heart Failure Status: The patient has HFpEF, which affects approximately half of all heart failure patients and is associated with:

  • Severe exercise intolerance
  • Exertional dyspnea
  • Early-onset fatigue with physical activity 1
  • Impaired quality of life and increased mortality risk

• Comorbidities: The combination of HFpEF with T2DM and hypertension creates a high-risk profile:

  • T2DM in HFpEF patients is associated with reduced exercise capacity, impaired heart rate response, and decreased peripheral oxygen extraction 2
  • Hypertension is a major risk factor for HF development 1

Assessment Algorithm

1. First Step: Exercise Capacity Assessment

   • Determine metabolic equivalents (METs) the patient can achieve
   • Can be assessed through standardized questionnaires or formal testing
   • Poor exercise capacity (<4 METs) would indicate higher perioperative risk

2. If Exercise Capacity is Poor:

   • Consider pharmacological stress echocardiogram to further evaluate cardiac function under stress
   • This would provide information about inducible ischemia and ventricular function

3. If Exercise Capacity is Adequate:

   • No further cardiac testing needed
   • Proceed with optimization of current medications

Why Other Options Are Less Appropriate

• Option A (No further evaluation): Inappropriate given the elevated RCRI score of 6% and multiple cardiac risk factors
• Option B (Exercise stress ECG): Less suitable for a patient with HFpEF who may have limited exercise capacity
• Option C (Pharmacological stress echocardiogram): Would be appropriate only after determining that exercise capacity is inadequate

Management Considerations

• Medication Management: Continue valsartan for blood pressure control and heart failure management
• Volume Status: Ensure optimal volume status with appropriate diuretic dosing (furosemide)
• Glycemic Control: Current HbA1c of 7.2% indicates suboptimal control; consider perioperative glycemic management

Common Pitfalls to Avoid

1. Overreliance on RCRI score alone without considering functional capacity
2. Unnecessary cardiac testing in patients with adequate functional capacity
3. Failing to optimize modifiable risk factors before surgery (blood pressure, volume status, glycemic control)
4. Not considering the specific impact of HFpEF on perioperative risk

Exercise capacity assessment provides the most clinically relevant information for risk stratification in this patient with multiple cardiac risk factors facing intermediate-risk surgery, making it the best next step in preoperative evaluation.