Absolute Stop Points for Preoperative Cardiovascular Clearance
Surgery must be postponed or cancelled if any active cardiac condition is present, as these require evaluation and treatment before proceeding with noncardiac surgery. 1
Active Cardiac Conditions That Mandate Stopping (Class I, Level B)
These are absolute contraindications to proceeding with elective surgery:
Unstable Coronary Syndromes
- Unstable angina or severe angina (CCS Class III or IV) - including "stable" angina in unusually sedentary patients 1
- Recent myocardial infarction - defined as occurring more than 7 days but within 30 days of planned surgery 1
Decompensated Heart Failure
Significant Arrhythmias
- High-grade atrioventricular block (Mobitz II or third-degree heart block) 1
- Symptomatic ventricular arrhythmias 1
- Newly recognized ventricular tachycardia 1
- Supraventricular arrhythmias with uncontrolled ventricular rate (heart rate >100 bpm at rest, including atrial fibrillation) 1
- Symptomatic bradycardia 1
Severe Valvular Disease
- Severe aortic stenosis - mean gradient >40 mmHg, valve area <1.0 cm², or symptomatic 1
- Symptomatic mitral stenosis - progressive dyspnea on exertion, exertional presyncope, or heart failure 1
When Further Workup Is Required Before Clearance
Order additional cardiac testing only if results will change the surgical procedure, alter medical therapy or monitoring, or lead to postponement until the cardiac condition is stabilized. 1, 2
Poor Functional Capacity
- Inability to perform 4 METs of activity (cannot climb a flight of stairs, walk on level ground at 4 mph, or do heavy housework) warrants further evaluation in patients with clinical risk factors 1, 2
- Conversely, a high-risk patient who is asymptomatic and exercises regularly (e.g., runs 30 minutes daily) may need no further testing 1
Emergency Surgery Exception
- In acute surgical emergencies, limit evaluation to rapid assessment of vital signs, volume status, hematocrit, electrolytes, renal function, urinalysis, and ECG only 1
- Proceed with only the most essential interventions until the emergency is resolved 1
- Conduct more thorough evaluation after surgery 1
Critical Pitfalls to Avoid
Never use the phrase "cleared for surgery" in your consultation note. 1, 2 This oversimplifies the consultant's role and fails to communicate the nuanced cardiovascular risk assessment. Instead, provide a comprehensive assessment of cardiovascular status and specific recommendations for perioperative management.
Do not order tests that will not change management. 1, 2 For example, in patients where coronary revascularization is not an option, noninvasive stress testing is often unnecessary 1.
Avoid redundant testing. 1 Before ordering additional diagnostic tests, ensure the information has potential to affect treatment decisions 1.
Communication Requirements
Your consultation must include:
- Direct communication with the surgeon, anesthesiologist, and other physicians 1
- Frank discussion with the patient and family when appropriate 1
- Clear documentation of cardiovascular stability and whether the patient is in optimal medical condition within the context of the surgical illness 1
- Specific recommendations for medication changes, preoperative tests, procedures, or higher levels of postoperative care 1