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

Writing a Cardiac Clearance Note: Key Components and Structure

A cardiac clearance note should not simply provide "clearance for surgery" but rather perform a comprehensive evaluation of the patient's current medical status and provide recommendations for perioperative cardiac risk management.1

Essential Components

Patient and Procedure Information

• Include complete patient demographics (name, age, gender) 2
• Document the planned procedure with date and urgency level 2
• Specify the type of anesthesia anticipated 1

Comprehensive Cardiac Assessment

• History

  • Document current cardiac symptoms (angina, dyspnea, palpitations, syncope) 2
  • List all cardiovascular diagnoses (CAD, heart failure, valvular disease, arrhythmias) 2
  • Record cardiovascular risk factors (hypertension, diabetes, hyperlipidemia, smoking) 2
  • Document current medications with dosages, including herbal supplements 1
  • Note any history of pacemaker, ICD, or orthostatic intolerance 1
  • Document alcohol, tobacco, and drug use 1

• Functional Capacity Assessment

  • Evaluate and document the patient's ability to perform daily activities in METs 1, 2
  • Note if patient can perform >4 METs (climb stairs, walk on level ground at 4 mph, do light housework) 1
  • Document if patient has limited functional capacity (<4 METs) 1

Physical Examination Findings

• Record vital signs including heart rate and blood pressure 1
• Document cardiovascular examination findings (heart sounds, murmurs, gallops) 1
• Note any signs of heart failure (JVD, edema, pulmonary rales) 1

Diagnostic Test Results

• Include ECG findings with date 2
• Document echocardiogram results if performed, including LVEF, wall motion, and valvular function 2
• Include results of any stress tests or other cardiac imaging if performed 1
• Note that tests should only be performed if they will change management 1

Risk Assessment and Recommendations

Risk Stratification

• Classify surgical risk category (low, intermediate, high) 2
• Calculate and document risk score (e.g., RCRI) if applicable 2
• Identify active cardiac conditions that may require delay of surgery (Table 2 in guidelines) 1

Specific Recommendations

• Provide explicit statement regarding cardiac risk assessment 2
• Recommend perioperative medication management (which medications to continue/hold) 2
  • Consider holding ACE inhibitors and ARBs 24 hours before surgery 3
  • Address antiplatelet therapy management, especially with recent stents 2
• Avoid phrases like "clear for surgery" which do not provide specific recommendations 1

Follow-up Plan

• Provide post-procedure cardiac follow-up recommendations 2
• Document parameters for seeking immediate cardiac consultation 2
• Consider long-term cardiac risk reduction strategies 1

Common Pitfalls to Avoid

• Avoid providing "medical clearance" without specific recommendations 1

  • The consultant should not use phrases such as "clear for surgery" but rather provide a comprehensive assessment 1

• Avoid ordering unnecessary tests 1

  • Tests should only be performed if they will change management 1
  • Strong recommendations exist against routine preoperative resting echocardiography, coronary CT angiography, or stress testing 3

• Avoid missing the opportunity for long-term risk reduction 1

  • The perioperative evaluation may be the ideal opportunity to effect long-term treatment of cardiac disease 1

• Ensure clear communication with all providers 1

  • Direct communication with surgeon, anesthesiologist, and other physicians is essential 1
  • Ensure findings and impressions will be incorporated effectively into the patient's overall plan of care 1

Remember that the goal of the consultation is the optimal care of the patient, not simply to provide "clearance" for a procedure 1.