When is preoperative cardiology clearance required?

When to Request Preoperative Cardiology Clearance

Preoperative cardiology clearance should be requested for patients with active cardiac conditions including unstable coronary syndromes, decompensated heart failure, significant arrhythmias, or severe valvular disease before proceeding with noncardiac surgery. 1

Active Cardiac Conditions Requiring Evaluation Before Surgery

• Unstable coronary syndromes: Unstable or severe angina (CCS class III or IV), recent myocardial infarction (within 30 days) 1
• Decompensated heart failure: NYHA functional class IV, worsening or new-onset heart failure 1
• Significant arrhythmias: High-grade atrioventricular block, symptomatic ventricular arrhythmias, supraventricular arrhythmias with uncontrolled ventricular rate (HR >100 bpm at rest), symptomatic bradycardia, newly recognized ventricular tachycardia 1
• Severe valvular disease: Severe aortic stenosis (mean pressure gradient >40 mm Hg, aortic valve area <1.0 cm², or symptomatic), symptomatic mitral stenosis 1

Risk-Based Approach for Cardiac Evaluation

High-Risk Surgery (Vascular Procedures)

• Patients with 3 or more clinical risk factors and poor functional capacity (<4 METs): Noninvasive stress testing is reasonable if it will change management 1
• Patients with at least 1 clinical risk factor: Preoperative resting 12-lead ECG is recommended 1
• Patients with no clinical risk factors: Preoperative resting 12-lead ECG is reasonable 1

Intermediate-Risk Surgery

• Patients with known coronary heart disease, peripheral arterial disease, or cerebrovascular disease: Preoperative resting 12-lead ECG is recommended 1
• Patients with at least 1 clinical risk factor and poor functional capacity (<4 METs): Noninvasive stress testing may be considered if it will change management 1
• Patients with at least 1 clinical risk factor: Preoperative resting 12-lead ECG may be reasonable 1

Low-Risk Surgery

• Asymptomatic patients: Preoperative and postoperative resting 12-lead ECGs are not indicated 1
• Patients can proceed to surgery without further cardiac testing 2

Assessment of Left Ventricular Function

• Patients with current or poorly controlled heart failure: Preoperative evaluation of LV function is recommended 1
• Patients with dyspnea of unknown origin: Preoperative evaluation of LV function is reasonable 1, 2
• Patients with prior heart failure with worsening dyspnea or change in clinical status: Preoperative evaluation of LV function is reasonable if not performed within 12 months 1, 2
• Clinically stable patients with previously documented cardiomyopathy: Reassessment of LV function is not well established 1

Important Considerations

• Purpose of preoperative evaluation: The goal is not to "clear" patients for surgery but to assess and optimize cardiac status, make recommendations for perioperative management, and provide a clinical risk profile 1, 3
• Avoid unnecessary testing: Tests should only be performed if they will influence patient treatment 1, 3
• Communication is critical: Ensure clear communication between the consultant, surgeon, anesthesiologist, and other physicians involved in the patient's care 1, 3
• Long-term management: The perioperative evaluation may be an opportunity to address long-term treatment of significant cardiac disease 1

Common Pitfalls to Avoid

• Viewing preoperative evaluation as simply "giving medical clearance" rather than a comprehensive risk assessment 3
• Performing tests that will not influence perioperative management 3
• Using phrases such as "clear for surgery" which do not adequately communicate the patient's risk profile 1
• Failing to communicate findings and recommendations to all members of the perioperative team 3

By following these evidence-based guidelines, clinicians can appropriately identify patients who require preoperative cardiology clearance, optimize their management, and improve perioperative outcomes.