Requirements for Surgical Clearance
Surgical clearance should be tailored to the patient's specific medical conditions and the planned procedure, focusing on identifying and optimizing active cardiac conditions, assessing functional capacity, and evaluating surgical risk rather than performing routine laboratory tests that don't impact management. 1
Key Components of Surgical Clearance
History and Physical Examination
- Identify serious cardiac conditions such as unstable coronary syndromes, prior angina, recent/past MI, decompensated heart failure, significant arrhythmias, and severe valvular disease 1
- Document history of pacemakers, implantable cardioverter defibrillators, or orthostatic intolerance 1
- Record modifiable risk factors for coronary heart disease and evidence of associated diseases (peripheral vascular disease, cerebrovascular disease, diabetes mellitus, renal impairment, chronic pulmonary disease) 1
- Note any recent changes in symptoms for patients with established cardiac disease 1
- Document current medications, including herbal/nutritional supplements, and dosages 1
- Record use of alcohol, tobacco, over-the-counter and illicit drugs 1
Functional Capacity Assessment
- Evaluate the patient's ability to perform daily tasks, which correlates with maximum oxygen uptake 1
- Patients with good functional capacity (>4 METs) generally have lower perioperative risk, even with clinical risk factors 1
- Examples of moderate functional capacity (4 METs) include climbing a flight of stairs, walking on level ground at 4 mph, or doing light work around the house 1
Active Cardiac Conditions Requiring Evaluation Before Surgery
- Unstable coronary syndromes (unstable/severe angina, recent MI) 1
- Decompensated heart failure (NYHA class IV, worsening or new-onset HF) 1
- Significant arrhythmias (high-grade AV block, symptomatic ventricular arrhythmias, supraventricular arrhythmias with uncontrolled ventricular rate) 1
- Severe valvular disease (severe aortic stenosis, symptomatic mitral stenosis) 1
Perioperative Management of Medications
- For patients on direct oral anticoagulants (DOACs) requiring elective surgery:
- Preoperative bridging with LMWH or heparin is not recommended in NOAC-treated patients 1
Laboratory Testing Guidelines
- Routine preoperative laboratory testing is not recommended for low-risk ambulatory surgery and contributes little to patient care 2, 3, 4
- Studies show 60% of routinely ordered tests would not have been performed if testing had only been done for recognizable indications 2
- Neither routine testing nor abnormal results were associated with postoperative complications in low-risk ambulatory surgery 4
- A large study of cataract surgery patients found no difference in complication rates between patients who received routine preoperative testing and those who did not 5
Common Pitfalls to Avoid
- Using phrases like "clear for surgery" - instead, provide a comprehensive assessment addressing all relevant aspects of cardiovascular health 1
- Ordering routine laboratory tests without specific indications - this increases costs without improving outcomes 3, 6
- Failing to communicate directly with the surgeon, anesthesiologist, and other physicians involved in the patient's care 1
- Not considering the long-term treatment of patients with significant cardiac disease or risk factors 1
- Delaying surgery unnecessarily when patients have good functional capacity, even with clinical risk factors 1
Surgical Risk Stratification
- If the estimated 30-day cardiac risk of the procedure is low (<1%), it's usually appropriate to proceed with the planned surgery 1
- For patients with unstable conditions (Table 12), the condition should be clarified and treated appropriately before surgery 1
- In patients with extensive stress-induced ischemia, individualized perioperative management is recommended, considering the potential benefit of the proposed surgery versus predicted adverse outcomes 1