Who should be evaluated for cardiac co-morbidities?

Who Should Be Evaluated for Cardiac Comorbidities

All patients with existing cardiovascular disease should be evaluated for cardiac comorbidities, as having cardiovascular disease without at least one comorbid chronic condition is the exception rather than the rule. 1

High-Priority Populations Requiring Cardiac Comorbidity Evaluation

Patients with Established Cardiovascular Disease

• Any patient with ischemic heart disease, heart failure, atrial fibrillation, or stroke requires systematic evaluation for cardiac comorbidities, as these index conditions are almost universally accompanied by multiple chronic conditions 1
• Patients over 65 years with any cardiovascular condition have an 81-89% prevalence of hypertension, 62-70% prevalence of hyperlipidemia, and 37-47% prevalence of diabetes mellitus 1
• 36% of patients with ischemic heart disease also have heart failure, requiring evaluation for both conditions 1, 2

Age-Based Screening

• All asymptomatic adults aged >40 years without evidence of CVD, diabetes, CKD, or familial hypercholesterolemia should undergo total cardiovascular risk estimation using a validated risk-estimation system 1
• Patients ≥50 years are at 3-fold increased risk for perioperative cardiac complications and require aggressive cardiac evaluation 1, 3
• All individuals aged <50 years with a family history of premature CVD in a first-degree relative (<55 years in men, <65 years in women) should be screened for familial hypercholesterolemia using a validated clinical score 1

Preoperative Evaluation

• Patients undergoing vascular procedures or complicated, prolonged abdominal, thoracic, and head and neck procedures require cardiac comorbidity evaluation 1
• Any patient with functional capacity <4 METs (unable to climb one flight of stairs carrying groceries, walk 2 blocks on level ground, or do heavy housework) has increased perioperative cardiac and long-term risks requiring evaluation 1
• Patients with major clinical predictors require immediate evaluation: unstable coronary syndromes, decompensated heart failure, significant arrhythmias (high-grade AV block, symptomatic ventricular arrhythmias, supraventricular arrhythmias with uncontrolled rate), or severe valvular disease 1

Specific Comorbidity-Based Triggers

Diabetes mellitus patients require cardiac evaluation when:

• They have type 1 diabetes or require insulin therapy 1, 2
• They are diabetic with pre-existing cardiac disease (especially high-risk group) 3
• They have diabetes as part of a triad with hypertension and hyperlipidemia (31.7% prevalence in Medicare beneficiaries) 1

Chronic kidney disease patients require cardiac evaluation when:

• Creatinine ≥2 mg/dL (180 μmol/L) 1
• They are among the 30-45% of cardiovascular patients who have concurrent CKD 1, 2

Pulmonary disease patients require cardiac evaluation when:

• They have COPD, as this significantly increases mortality from ischemic heart disease and perioperative complications 1
• 20% of COPD patients entering pulmonary rehabilitation have ischemic ECG changes requiring cardiac workup 1

Other high-risk comorbidities requiring cardiac evaluation:

• Anemia (present in 39-51% of cardiovascular patients) 1, 2
• Peripheral vascular disease 1
• History of cerebrovascular disease or stroke 1
• Depression (associated with poorer cardiovascular outcomes) 1, 2

Specific Evaluation Triggers in Symptomatic Patients

• Patients with new or worsening symptoms require expeditious cardiac evaluation with risk stratification using stress imaging or exercise stress ECG 1
• Deteriorating LV systolic function not attributable to reversible causes (e.g., tachycardia, myocarditis) mandates reassessment of CAD status 1
• Patients with characteristic episodic resting angina and ST-segment changes that resolve with nitrates and/or calcium antagonists require invasive angiography or coronary CTA 1
• Exertion-related dizziness or chest pain with or without history of respiratory failure requires echocardiography 1

Common Pitfalls to Avoid

• Do not assume younger patients (<50 years) without symptoms are low-risk if they have a family history of premature CVD—they require screening 1
• Do not rely solely on traditional risk factors (hypertension, hyperlipidemia, diabetes, smoking) for risk stratification, as age, sex, and race capture 63-80% of prognostic performance, while individual risk factors add only 0.004-0.013 to the C index 4
• Baseline resting ECG should be considered in preoperative evaluation, as 20% of patients have ischemic changes 1
• Do not overlook underreported comorbidities such as obesity, depression, cognitive impairment, and frailty, which become increasingly common with age 1