From the Guidelines
Patients with active cardiac conditions, significant cardiac risk factors, or poor functional capacity require preoperative cardiology clearance in addition to medical clearance. Specifically, patients with unstable coronary syndromes (unstable angina, recent MI within 30 days), decompensated heart failure, significant arrhythmias (high-grade AV block, symptomatic ventricular arrhythmias, supraventricular arrhythmias with uncontrolled ventricular rate), and severe valvular disease should receive cardiology evaluation before surgery 1. Additionally, patients with stable cardiac disease but undergoing high-risk procedures (vascular surgery, prolonged procedures with large fluid shifts), those with poor functional capacity (unable to climb two flights of stairs or perform 4 METs of activity), multiple cardiac risk factors (diabetes, renal insufficiency, history of stroke, coronary artery disease), or abnormal cardiac testing results should be referred for cardiology clearance 1.
The rationale for this additional evaluation is to identify patients at increased risk for perioperative cardiac events, optimize medical therapy before surgery (such as beta-blockers, statins, antiplatelet agents), determine if further cardiac testing is needed, and develop appropriate perioperative management strategies to reduce complications and mortality. Key considerations include:
- Unstable cardiac conditions that may require stabilization before surgery
- Significant cardiac risk factors that may necessitate further evaluation or optimization of medical therapy
- Poor functional capacity that may impact the patient's ability to tolerate surgery
- High-risk procedures that may require specialized perioperative care
According to the American College of Cardiology/American Heart Association guidelines, an electrocardiogram (ECG) is recommended for patients with known heart disease, peripheral vascular disease, or cerebrovascular disease who are undergoing intermediate- or high-risk surgery, as well as for patients with one or more clinical risk factors who are undergoing vascular surgery 1. The consultant should provide a comprehensive assessment that addresses all relevant aspects of the patient's cardiovascular health, rather than simply "clearing" the patient for surgery 1.