Is a 50-year-old patient with normal laboratory results, sinus bradycardia (EKG showing 50 beats per minute), and no other underlying conditions clear for hammertoe and cyst removal surgery on the left toe?

Preoperative Clearance for Low-Risk Surgery with Asymptomatic Sinus Bradycardia

This patient is clear to proceed with hammertoe and cyst removal surgery without further cardiac evaluation or delay. 1

Rationale for Clearance

Surgery Risk Classification

• Hammertoe and cyst removal on the toe is a low-risk surgical procedure (not vascular, intra-abdominal, thoracic, or major orthopedic surgery). 2
• Low-risk procedures carry minimal perioperative cardiac morbidity and mortality risk, even in patients with cardiac findings. 1

Assessment of Bradycardia

The sinus bradycardia at 50 bpm does NOT constitute a contraindication to surgery in this case. 1

The ACC/AHA guidelines specifically define "significant arrhythmias" that mandate stopping surgery, and this patient does not meet any of these criteria:

• Symptomatic bradycardia is the contraindication—not asymptomatic bradycardia. 1, 3
• The patient is healthy with an unremarkable exam and no symptoms (no syncope, dizziness, fatigue, or exercise intolerance). 1
• Sinus bradycardia of 50 bpm falls within the range of 40-50 bpm that can be physiologically normal, particularly in well-conditioned individuals. 1
• There is no evidence of high-grade AV block, Mobitz II block, third-degree heart block, or other significant conduction abnormalities. 1

Active Cardiac Conditions Assessment

This patient has NO active cardiac conditions that would mandate postponing surgery. 1, 3

The ACC/AHA guidelines require stopping only for:

• Unstable coronary syndromes (not present). 1, 3
• Decompensated heart failure (not present). 1, 3
• Symptomatic bradycardia or other significant arrhythmias (not present—this bradycardia is asymptomatic). 1, 3
• Severe valvular disease (not present). 1, 3

Intraoperative Management Considerations

Monitoring Recommendations

• Standard ASA monitoring is sufficient for this low-risk procedure. 1
• Consider placement of transcutaneous pacing pads if the anesthesiologist anticipates potential for further bradycardia during the procedure (though this is reasonable, not mandatory). 1
• The patient's baseline heart rate of 50 bpm should be documented as the patient's normal baseline to avoid unnecessary intervention intraoperatively. 1

Common Pitfall to Avoid

Do not delay surgery for unnecessary cardiac testing. 1, 3

• The ACC/AHA explicitly states that preoperative tests should only be ordered if results will change the surgical procedure, alter medical therapy/monitoring, or lead to postponement until cardiac stabilization. 1, 3
• In this asymptomatic patient undergoing low-risk surgery, no additional cardiac workup (echocardiogram, stress test, Holter monitor, or cardiology consultation) is indicated. 1, 3
• Postoperative troponin measurement is not recommended in asymptomatic stable patients undergoing low-risk surgery. 1

Documentation Guidance

Avoid using the phrase "cleared for surgery" in your consultation note. 3

Instead, document:

• "The patient has no active cardiac conditions requiring treatment before surgery." 1, 3
• "Asymptomatic sinus bradycardia at 50 bpm noted; this does not constitute a contraindication to low-risk surgery." 1
• "Patient is in optimal medical condition for the planned procedure." 1, 3
• "Standard perioperative monitoring is appropriate." 1