What is the proper preoperative workup for a 40-year-old female with intermittent chest pain and no cardiac history undergoing robotic inguinal hernia repair, with a normal electrocardiogram (EKG) showing no ischemic pattern?

Preoperative Workup for 40-Year-Old Female with Intermittent Chest Pain Before Robotic Inguinal Hernia Repair

This patient can proceed directly to surgery with guideline-directed medical therapy (GDMT) without further cardiac testing, as she has no active cardiac conditions, a normal EKG, and is undergoing low-risk surgery. 1

Risk Stratification

Robotic inguinal hernia repair is classified as low-risk surgery with minimal fluid shifts and physiologic stress, similar to other minimally invasive procedures. 1 The 2014 ACC/AHA perioperative guidelines explicitly state that routine preoperative testing is not indicated for low-risk surgical procedures, even in symptomatic patients. 1

Patient-Specific Risk Assessment

This 40-year-old female has:

• Zero Revised Cardiac Risk Index (RCRI) factors (no history of ischemic heart disease, heart failure, cerebrovascular disease, diabetes requiring insulin, or renal insufficiency with creatinine >2 mg/dL) 1
• No active cardiac conditions requiring urgent evaluation (no unstable angina, recent MI, decompensated heart failure, significant arrhythmias, or severe valvular disease) 1
• Normal EKG without ischemic changes (no ST-segment deviation, new Q waves, or T-wave inversions) 1

With 0 RCRI factors, her risk of major adverse cardiac events (MACE) is <1%, which is considered low risk. 1

Characterization of Chest Pain

The intermittent nature of her chest pain requires clinical assessment to determine likelihood of acute coronary syndrome (ACS):

High-risk features that would change management (none present in this case):

• Prolonged chest pain at rest >20 minutes 1
• Hemodynamic instability, diaphoresis, or pulmonary edema 1
• Pain radiating to left arm, neck, or jaw with associated dyspnea or nausea 1
• Accelerating tempo of symptoms in preceding 48 hours 1

Low-risk features (consistent with this presentation):

• Intermittent (not persistent) chest pain 1
• Normal EKG 1
• No cardiac history 1
• Age 40 years (lower pretest probability) 1

Recommended Workup Algorithm

Step 1: Clinical Evaluation

• Obtain detailed chest pain characteristics: timing, quality, radiation, exacerbating/relieving factors, and associated symptoms 1
• Assess for non-cardiac causes: musculoskeletal pain (reproducible with palpation), gastrointestinal causes (epigastric pain, relation to meals), anxiety, or pleuritic features 1
• Physical examination: vital signs including blood pressure in both arms, cardiac auscultation for murmurs, lung examination, and chest wall palpation 1, 2

Step 2: Basic Laboratory Assessment

Obtain cardiac troponin if any concern for ACS based on clinical features, even with normal EKG. 1, 2 The European Society of Cardiology recommends high-sensitivity troponin as the preferred biomarker for myocardial injury. 1, 2

Do NOT obtain routine stress testing, echocardiography, or coronary angiography for low-risk surgery in asymptomatic or low-risk patients. 1 The 2014 ACC/AHA guidelines give this a Class III (No Benefit) recommendation. 1

Step 3: Proceed to Surgery Decision Tree

If troponin is negative and chest pain characteristics are low-risk:

• Proceed directly to surgery with GDMT 1
• No further cardiac testing required 1
• Ensure continuation of any existing cardiac medications perioperatively 1

If troponin is elevated or chest pain has high-risk features:

• Delay surgery and evaluate for ACS per standard protocols 1
• Obtain serial troponins at 3,6, and 9-12 hours 2
• Perform serial EKGs every 2-4 hours 2
• Cardiology consultation for risk stratification and potential stress testing or angiography 1

Key Guideline Recommendations

The 2014 ACC/AHA perioperative guidelines provide clear direction:

Class III (No Benefit) - Do NOT perform:

• Routine preoperative 12-lead ECG for asymptomatic patients undergoing low-risk surgery 1
• Routine screening with noninvasive stress testing for low-risk noncardiac surgery 1
• Routine preoperative coronary angiography 1

Class IIa (Reasonable) - Consider only if:

• Patient has elevated risk (≥2 RCRI factors) AND poor functional capacity (<4 METs) AND it will change management 1
• This patient does not meet these criteria 1

Critical Pitfalls to Avoid

Do not over-test low-risk patients. The most common error is ordering unnecessary stress tests or echocardiograms for patients undergoing low-risk surgery, which delays surgery without improving outcomes and may lead to false-positive results requiring further unnecessary testing. 1

Do not dismiss atypical chest pain in women. While this patient is low-risk, women more commonly present with atypical symptoms of ACS (epigastric pain, dyspnea without chest pain, fatigue). 1 A single troponin measurement is reasonable if clinical suspicion exists. 2

Do not confuse surgical approach with surgical risk. Although this is "robotic" surgery, the procedure itself (inguinal hernia repair) remains low-risk regardless of approach. 1, 3, 4, 5 Robotic inguinal hernia repair has similar outcomes to laparoscopic and open approaches with mean operative times of 52-105 minutes and same-day discharge. 3, 4, 6

Practical Management Summary

For this specific patient:

1. Obtain single troponin level to exclude acute myocardial injury given chest pain symptoms 2
2. If troponin negative: proceed to surgery without delay 1
3. If troponin positive: delay surgery and complete ACS evaluation with serial troponins, serial EKGs, and cardiology consultation 1, 2
4. Ensure adequate anesthesia consultation regarding pain management, as robotic inguinal hernia repair typically involves minimal postoperative pain with return to regular activity within 4 days 4

The evidence strongly supports that additional preoperative cardiac testing beyond a single troponin (if clinically indicated) provides no benefit and may cause harm through unnecessary delays in this low-risk scenario. 1