What information should be included in the heart and lung section of the History and Physical (H&P) for surgery clearance?

Heart and Lung Section of H&P for Surgery Clearance

Your H&P must identify active cardiac conditions that mandate stopping surgery, assess functional capacity, and document pulmonary reserve—these directly determine perioperative mortality risk.

Cardiac History: Critical Elements to Document

Active Cardiac Conditions (Surgery Must Be Postponed)

Document presence or absence of these specific conditions, as they are absolute contraindications to elective surgery 1, 2:

• Unstable angina or severe angina (CCS Class III or IV) 1, 2
• Recent myocardial infarction (within 7-30 days of planned surgery) 1, 2
• Decompensated heart failure (NYHA Class IV, worsening symptoms, or new-onset HF) 1, 2
• Significant arrhythmias: high-grade AV block, Mobitz II or third-degree heart block, symptomatic ventricular arrhythmias, atrial fibrillation with uncontrolled rate (>100 bpm at rest), symptomatic bradycardia, or newly recognized ventricular tachycardia 1, 2
• Severe valvular disease: severe aortic stenosis (mean gradient >40 mmHg, valve area <1.0 cm², or symptomatic) or symptomatic mitral stenosis 1, 2

Cardiac History Details

• Prior MI: Document timing (especially if within 6 months) 1
• Coronary revascularization: Prior CABG or PCI with stent placement 1, 3
• Heart failure: Document NYHA class, recent decompensation, or changes in symptoms 1, 4
• Arrhythmias: Presence of pacemaker or ICD 1
• Valvular disease: Known stenosis or regurgitation, especially if symptomatic 1
• Functional capacity: Ability to climb 2 flights of stairs or perform 4 METs of activity (inability indicates poor functional capacity requiring further workup) 2, 3

Current Medications

Document all cardiac medications with exact dosages, including herbal supplements 1. This is essential for perioperative management.

Cardiac Physical Examination: Key Findings

• Displaced cardiac apex: Suggests ventricular enlargement and heart failure 4
• Third heart sound (S3): Highly specific for heart failure 4
• Cardiac murmurs: Any audible murmur requires echocardiography 1, 5
• Signs of volume overload: Peripheral edema, jugular venous distension, pulmonary rales 4
• Vital signs: Heart rate and rhythm, blood pressure 1

Pulmonary History: Essential Documentation

Chronic Lung Disease

• COPD: Most common risk factor for postoperative pulmonary complications (odds ratio 1.79) 5
• Asthma: Current control status and recent exacerbations 5
• Obstructive sleep apnea: Significant risk factor for complications 5
• Interstitial lung disease: Affects surgical candidacy even with adequate spirometry 1

Functional Pulmonary Status

• Dyspnea: Progressive exertional dyspnea, exercise intolerance, or unexpected disability with shortness of breath 1
• Smoking history: Current or former use 1
• Recent pulmonary infections or exacerbations 5

For Lung Resection Surgery Specifically

Document baseline pulmonary function if available 1, 5:

• Post-bronchodilator FEV1 values (>1.5L for lobectomy, >2.0L for pneumonectomy indicates average risk) 1, 5
• Transfer factor (TLCO) if previously measured 1, 5
• Oxygen saturation at rest 1, 5

Pulmonary Physical Examination

• Respiratory rate and pattern 5
• Oxygen saturation on room air 1, 5
• Chest auscultation: Wheezing, crackles, decreased breath sounds 4
• Signs of respiratory distress: Use of accessory muscles, pursed-lip breathing 5

Additional Risk Factors to Document

• Age: ≥65 years significantly increases pulmonary complication risk 5
• Functional dependence: Inability to perform activities of daily living 5
• Weight loss: >10% preoperative weight loss indicates high risk 1, 5
• Nutritional status: Body mass index and serum albumin (low values increase complication risk) 1, 5
• Performance status: WHO performance status ≥2 indicates need for careful assessment 1

Critical Communication Points

Never use the phrase "cleared for surgery"—this oversimplifies your role and fails to communicate nuanced cardiovascular risk 2. Instead, document:

• Whether active cardiac conditions are present that mandate postponement 1, 2
• Patient's cardiovascular stability and optimal medical condition within the surgical context 1, 2
• Specific recommendations for medication changes, additional testing, or higher postoperative care levels 2
• Whether additional cardiac or pulmonary testing would change management (if not, don't order it) 1, 2

Common Pitfalls to Avoid

• Ordering routine testing without clinical indication: Preoperative tests should only be ordered if results will change surgical approach, medical therapy, or monitoring 1, 2, 5
• Missing functional capacity assessment: Poor functional capacity (<4 METs) with clinical risk factors requires further evaluation 2, 3
• Relying on history alone for COPD: PFTs reclassify COPD status in 31% of patients and provide critical prognostic information 6
• Inadequate attention to pulmonary complications: These are as prevalent and contribute similarly to mortality as cardiac complications 5