What are the key components to include when writing a note for cardiac clearance?

Writing a Comprehensive Cardiac Clearance Note

A comprehensive cardiac clearance note should include detailed assessment of cardiovascular risk factors, functional capacity, and specific cardiac conditions to determine perioperative risk and provide clear recommendations for the planned procedure.

Essential Components of a Cardiac Clearance Note

1. Patient Identification and Procedure Details

• Patient demographics (name, age, gender) 1
• Planned procedure with date and urgency level 1
• Name of requesting provider/surgeon 1

2. Comprehensive Cardiac History

• Cardiovascular diagnoses (CAD, heart failure, valvular disease, arrhythmias) 1
• Prior cardiovascular procedures (including dates) 1
• Functional capacity assessment (in METs) 1
• Current cardiac symptoms (angina, dyspnea, palpitations, syncope) 1
• Cardiovascular risk factors (hypertension, diabetes, hyperlipidemia, smoking) 1

3. Detailed Medication Review

• Current cardiac medications with doses 1
• Anticoagulation/antiplatelet therapy status 1
• Medication allergies or significant side effects 1
• Recent medication changes 1

4. Relevant Physical Examination Findings

• Vital signs (BP, HR, RR, O2 saturation) 1
• Cardiovascular examination (heart sounds, murmurs, JVD) 1
• Pulmonary examination (breath sounds, edema) 1
• Other relevant systems based on comorbidities 1

5. Diagnostic Test Results

• ECG findings with date 1
• Echocardiogram results with date (LVEF, wall motion, valvular function) 1, 2
• Stress test results if performed (type, date, findings) 1
• Relevant laboratory values (troponin, BNP, creatinine) 3
• Other cardiac testing (coronary angiography, Holter) if applicable 1

6. Risk Assessment and Stratification

• Surgical risk category (low, intermediate, high) 1
• Patient-specific cardiac risk factors 1
• Calculated risk score if applicable (e.g., RCRI) 1
• Functional capacity assessment (>4 METs vs. <4 METs) 1

7. Clear Recommendations

• Explicit statement of cardiac clearance status (cleared, not cleared, or cleared with specific precautions) 1
• Perioperative medication management recommendations 1
• Monitoring recommendations (telemetry, ICU) 1
• Specific perioperative precautions if needed 1

8. Follow-up Plan

• Post-procedure cardiac follow-up recommendations 1
• Parameters for seeking immediate cardiac consultation 1
• Long-term cardiovascular risk reduction strategies 1

Special Considerations

Unstable Cardiac Conditions Requiring Stabilization Before Clearance

• Unstable coronary syndromes 1
• Decompensated heart failure 1
• Significant arrhythmias 1
• Severe valvular disease 1

Patients with Recent Coronary Interventions

• For bare metal stents: delay elective surgery for at least 6 weeks 1
• For drug-eluting stents: delay elective surgery for at least 12 months 1
• Antiplatelet management recommendations 1

Cardiac Device Management

• Pacemaker/ICD settings and perioperative management 1
• Need for device interrogation before/after procedure 1

Common Pitfalls to Avoid

• Failing to document functional capacity assessment 1
• Omitting explicit clearance statement with specific recommendations 1
• Inadequate assessment of medication management (especially anticoagulants) 1
• Not addressing specific cardiac risks relevant to the planned procedure 1
• Missing documentation of unstable cardiac conditions that require stabilization 1
• Incomplete documentation of test results that support clearance decision 1
• Not providing clear follow-up recommendations 1

Sample Template Structure

CARDIAC CLEARANCE NOTE

PATIENT: [Name, Age, Gender]
PLANNED PROCEDURE: [Procedure name, Date]
REQUESTING PROVIDER: [Name]

CARDIAC HISTORY:
- Cardiovascular diagnoses:
- Prior cardiovascular procedures:
- Current cardiac symptoms:
- Cardiovascular risk factors:
- Functional capacity (METs):

MEDICATIONS:
- Current cardiac medications:
- Anticoagulation/antiplatelet status:
- Medication allergies:

PHYSICAL EXAMINATION:
- Vital signs:
- Cardiovascular findings:
- Pulmonary findings:
- Other relevant findings:

DIAGNOSTIC TESTS:
- ECG (date):
- Echocardiogram (date):
- Stress test (date):
- Relevant labs:

RISK ASSESSMENT:
- Surgical risk category:
- Patient-specific risk factors:
- Risk score (if applicable):

RECOMMENDATIONS:
- Clearance status:
- Perioperative medication management:
- Monitoring recommendations:
- Specific precautions:

FOLLOW-UP PLAN:
- Post-procedure cardiac follow-up:
- Parameters for immediate consultation:
- Long-term risk reduction strategies:

[Signature, Date]

By following this structured approach, you will create a comprehensive cardiac clearance note that addresses all essential components while providing clear guidance for perioperative management 1.