What cardiac evaluation is recommended preoperatively for a 65-year-old male patient with a history of hyperlipidemia, Non-ST-Elevation Myocardial Infarction (NSTEMI), and aortic stenosis undergoing total knee replacement?

From the Guidelines

For preoperative cardiac evaluation of this 65-year-old male with hyperlipidemia, NSTEMI history, and aortic stenosis undergoing total knee replacement, I recommend a preoperative resting 12-lead ECG as it is reasonable for patients with known coronary heart disease or other significant structural heart disease, except for low-risk surgery 1. Given the patient's history of NSTEMI and aortic stenosis, which are significant structural heart diseases, a preoperative resting 12-lead ECG is warranted to assess for any changes that may indicate increased perioperative risk.

• The ECG will provide a baseline against which to measure changes in the postoperative period and contains prognostic information relating to short- and long-term morbidity and mortality 1.
• Additionally, considering the patient's elevated risk due to his cardiac history, a transthoracic echocardiogram to assess the severity of aortic stenosis and left ventricular function is also recommended, as it can provide crucial information on the patient's cardiac status before undergoing surgery.
• Cardiac biomarkers, such as troponin, should be checked to establish baseline values, given his history of NSTEMI.
• A cardiology consultation is strongly advised to optimize medical management before surgery, which may include continuing statins for hyperlipidemia and appropriate antiplatelet therapy, and to provide specific recommendations regarding perioperative management of cardiac medications, particularly if the patient is on anticoagulants.
• Stress testing may be considered based on the patient's functional capacity and the results of the initial evaluation, as it can help assess for myocardial ischemia and functional capacity, especially in patients with elevated risk and unknown or poor functional capacity 1.

From the Research

Preoperative Cardiac Evaluation for Total Knee Replacement

The patient's history of hyperlipidemia, NSTEMI, and aortic stenosis requires careful consideration in the preoperative evaluation for total knee replacement.

• Cardiac Risk Assessment: The patient's history of NSTEMI and aortic stenosis indicates a high cardiac risk 2, 3.
• Aortic Stenosis Evaluation: Given the patient's history of aortic stenosis, it is essential to assess the severity of the stenosis and the patient's symptoms 4.
• B-Type Natriuretic Peptide Levels and Global Longitudinal Strain: Measuring serum B-type natriuretic peptide levels and global longitudinal strain can help detect early myocardial dysfunction in patients with aortic stenosis 4.
• Exercise Stress Test: An abnormal exercise stress test may indicate an increased risk of cardiac complications during surgery 4, 3.
• Left Ventricular Ejection Fraction (LVEF) Assessment: Evaluating the patient's LVEF is crucial in assessing cardiac function, especially in patients with a history of NSTEMI 2, 3.
• Medication Management: The patient's current medications, including antiplatelet and anticoagulant therapy, should be carefully managed perioperatively to minimize the risk of bleeding and cardiac complications 2, 5.
• Venous Thromboembolism Prophylaxis: Aspirin may be considered for venous thromboembolism prophylaxis after total knee replacement, as it has been shown to be effective and safe in this setting 5.

These evaluations and assessments will help determine the patient's cardiac risk and guide the development of a perioperative management plan to minimize cardiac complications during total knee replacement surgery.