What is the recommended approach to charting cardiac surgical clearance?

How to Chart Cardiac Surgical Clearance

Avoid using the phrase "cleared for surgery" in your documentation—instead, provide a comprehensive cardiovascular risk assessment with specific perioperative management recommendations. 1, 2, 3

Essential Documentation Components

Patient Demographics and Procedure Details

• Document patient name, age, gender, and the specific planned surgical procedure with date and urgency level 3
• Specify the type of anesthesia anticipated 3
• Categorize surgical risk as low (<1% cardiac risk), intermediate, or high-risk (e.g., major vascular surgery) 1, 3

Cardiovascular History and Active Conditions

• Screen for active cardiac conditions that may require surgery delay: unstable coronary syndromes (unstable angina, recent MI within 30 days), decompensated heart failure (NYHA class IV, new-onset or worsening HF), significant arrhythmias (high-grade AV block, symptomatic ventricular arrhythmias, uncontrolled supraventricular arrhythmias), and severe valvular disease (severe aortic stenosis, symptomatic mitral stenosis) 1, 2
• Document all cardiovascular diagnoses including coronary artery disease, heart failure with ejection fraction, valvular disease specifics, and arrhythmias 3
• Note history of prior coronary interventions (stents with type and timing, CABG) and presence of cardiac implantable electronic devices (pacemaker, ICD) 1, 3
• Record cardiovascular risk factors: hypertension, diabetes mellitus, hyperlipidemia, smoking status, peripheral arterial disease, cerebrovascular disease, chronic kidney disease 1, 3

Functional Capacity Assessment

• Quantify functional capacity using the Duke Activity Status Index (DASI) or metabolic equivalents (METs)—patients with poor functional capacity (<4 METs or DASI <34) are at elevated perioperative risk 1, 3
• Document specific activities the patient can perform: self-care (2.75 METs), walking 1-2 blocks (2.75 METs), climbing stairs (5.5 METs), moderate housework (3.5 METs), yardwork (4.5 METs), recreational activities (6-7.5 METs) 1
• Poor functional capacity includes inability to climb a flight of stairs or walk 4 blocks 1

Current Medications

• List all current cardiac medications with dosages, including beta-blockers, ACE inhibitors, ARBs, antiplatelet agents (aspirin, P2Y12 inhibitors), anticoagulants, statins, and diuretics 1, 3
• Document herbal supplements and over-the-counter medications 1

Physical Examination Findings

• Record vital signs including heart rate and blood pressure 3, 4
• Document cardiovascular examination: heart sounds, presence of murmurs (grade and location), gallops (S3, S4) 3
• Note signs of heart failure: jugular venous distension, peripheral edema, pulmonary rales 3
• Assess volume status 1

Diagnostic Test Results

Electrocardiogram

• Include 12-lead ECG findings with date for patients with at least one clinical risk factor undergoing vascular procedures, or those with known cardiovascular disease, peripheral arterial disease, or cerebrovascular disease 1, 2, 3
• ECG is reasonable for elevated-risk asymptomatic patients without established cardiovascular disease 1
• Do not routinely obtain ECG for asymptomatic patients undergoing low-risk surgery 2

Echocardiography

• Document echocardiogram results with date, including left ventricular ejection fraction, wall motion abnormalities, and valvular function 3
• Echocardiography is indicated for suspected moderate or severe valvular stenosis/regurgitation if no prior echo within 1 year or significant clinical change, current or poorly controlled heart failure, dyspnea of unknown origin, or suspected new/worsening ventricular dysfunction 1, 2, 3
• Avoid routine preoperative echocardiography when it will not change management 3

Stress Testing and Other Studies

• Document results of any stress testing (exercise, pharmacologic) or coronary CT angiography if performed 1
• Stress testing should only be performed if results will impact decision-making or perioperative care—consider in patients with poor or unknown functional capacity and elevated calculated risk 1

Biomarkers

• Consider documenting preoperative BNP/NT-proBNP (abnormal if BNP >92 ng/L or NT-proBNP ≥300 ng/L) and troponin (abnormal if >99th percentile) for risk stratification in elevated-risk patients 1

Risk Stratification

Calculate Perioperative Risk

• Use the Revised Cardiac Risk Index (RCRI) or American College of Surgeons NSQIP risk calculator to estimate risk of major adverse cardiovascular events (MACE) 1, 3
• RCRI assigns 1 point each for: high-risk surgery, ischemic heart disease, heart failure, cerebrovascular disease, insulin-dependent diabetes, and creatinine >2 mg/dL 1, 4
• Document whether calculated risk is low (<1% MACE) or elevated (>1% MACE or RCRI >1) 1

Identify Risk Modifiers

• Note presence of severe valvular heart disease, severe pulmonary hypertension, elevated-risk congenital heart disease, recent stroke, or frailty 1
• For patients with prior coronary stents, document timing: elective surgery should be delayed at least 6 weeks after bare metal stent and at least 12 months after drug-eluting stent 3

Specific Recommendations Section

Explicit Clearance Statement

• Provide explicit statement of cardiac status: "Patient at [low/intermediate/high] risk for perioperative MACE based on [specific findings]" rather than simply "cleared for surgery" 2, 3
• State whether surgery can proceed, should be delayed for optimization, or requires additional evaluation 3

Perioperative Medication Management

• Specify which medications to continue perioperatively (typically beta-blockers, statins, ACE inhibitors/ARBs if euvolemic) and which to hold (e.g., diuretics, anticoagulants per protocol) 3, 4
• Provide explicit recommendations for antiplatelet therapy management in patients with coronary stents 3
• Consider beta-blocker initiation in patients with known ischemic heart disease if started 2-30 days before surgery, titrated to heart rate 60-70 bpm with systolic BP >100 mmHg 4

Monitoring Recommendations

• Recommend level of perioperative monitoring based on risk (standard monitoring vs. arterial line vs. ICU-level care) 1
• Consider postoperative troponin surveillance in elevated-risk patients 1

Long-Term Management

• Address opportunities for long-term cardiovascular risk reduction: smoking cessation (at least 4 weeks preoperatively), optimization of diabetes/hypertension, initiation of guideline-directed medical therapy for coronary disease or heart failure 2, 3, 4
• Recommend cardiology follow-up with specific timeframe if indicated 3

Parameters for Urgent Consultation

• Specify symptoms or findings that should prompt immediate cardiac consultation postoperatively (e.g., chest pain, dyspnea, hemodynamic instability) 3

Communication and Documentation Pitfalls to Avoid

• Never use vague phrases like "cleared for surgery," "okay for surgery," or "proceed with case"—these provide no actionable information 1, 2, 3
• Do not order tests that will not influence perioperative management or patient decision-making 1, 2, 3
• Ensure direct communication with surgeon, anesthesiologist, and primary care physician, not just written documentation 1, 3
• Do not miss the opportunity to address long-term cardiac risk reduction strategies 3, 4
• Avoid viewing the consultation as simply providing clearance rather than comprehensive risk assessment and management recommendations 1, 4