What is required for cardiac clearance in patients undergoing orthopedic surgery with a history of cardiac disease?

Cardiac Clearance for Orthopedic Surgeries in Patients with Cardiac Disease

A comprehensive cardiac evaluation is required for patients with cardiac disease undergoing orthopedic surgery, focusing on identifying and optimizing active cardiac conditions that increase perioperative risk.

Initial Assessment

• The cardiac evaluation must identify serious cardiac conditions including unstable coronary syndromes, prior angina, recent myocardial infarction (MI), decompensated heart failure (HF), significant arrhythmias, and severe valvular disease 1
• Document history of pacemakers, implantable cardioverter defibrillators (ICDs), and orthostatic intolerance 1
• Record any recent changes in cardiac symptoms in patients with established cardiac disease 1
• Document all current medications including dosages, as well as use of herbal supplements, alcohol, tobacco, and illicit drugs 1

Active Cardiac Conditions Requiring Evaluation and Treatment Before Surgery

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

Functional Capacity Assessment

• Evaluate the patient's ability to perform daily activities as this correlates with maximum oxygen uptake 1
• Patients who can perform activities requiring ≥4 METs (climbing stairs, walking on level ground at 4 mph, doing heavy housework) generally have lower perioperative risk 1
• A patient with known cardiac disease who is asymptomatic and exercises regularly may need less extensive evaluation than a sedentary patient 1

Physical Examination Components

• Vital signs (including blood pressure in both arms) 1
• Carotid pulse contour and bruits 1
• Jugular venous pressure and pulsations 1
• Lung auscultation 1
• Precordial palpation and auscultation 1
• Abdominal examination 1
• Extremity examination for edema and vascular integrity 1

Laboratory and Diagnostic Testing

• Preoperative tests should only be ordered if results will change surgical procedure, medical therapy, monitoring during/after surgery, or lead to postponement until cardiac condition is stabilized 1
• Avoid redundant testing; tests should have potential to affect treatment 1
• Anemia (hematocrit <28%) is associated with increased perioperative ischemia and complications in vascular surgery patients 1

Risk Stratification for Orthopedic Procedures

• Orthopedic procedures generally carry intermediate cardiac risk, with documented MI rates around 1.2% in high-risk patients 2
• Posterior spinal fusion carries higher risk (3.9 times higher) compared to total knee arthroplasty and 4.2 times higher than total hip arthroplasty 2
• Advanced age (>70 years) and urgent procedures significantly increase risk of major cardiac events 3

Important Considerations

• Avoid using phrases like "clear for surgery" in consultation notes 1
• Ensure clear communication between the consultant, surgeon, anesthesiologist, and other physicians 1
• The perioperative evaluation may be an opportunity to implement long-term cardiac risk reduction strategies 1
• Document findings clearly in the medical record 1

Pitfalls to Avoid

• Ordering tests that will not change management decisions 1
• Focusing only on short-term perioperative risk without addressing long-term cardiac risk management 1
• Underestimating the risk of specific orthopedic procedures like spinal fusion, which carries significantly higher cardiac risk than joint replacements 2
• Failing to recognize that even with normal preoperative testing, cardiac events can still occur (69% of major cardiac events occur in patients not meeting criteria for cardiac testing) 3