What is the next step in preoperative evaluation for a 62-year-old gentleman with hypertension, coronary artery disease, and a smoking history, with normal S1/S2, no murmur, no clicks, and an EKG showing left ventricular hypertrophy?

Preoperative Evaluation for Intermediate-Risk Surgery in a Patient with CAD, Hypertension, and LVH

For this 62-year-old gentleman with hypertension, coronary artery disease, smoking history, and ECG showing left ventricular hypertrophy undergoing intermediate-risk surgery, you should proceed directly to surgery with optimized medical management—no further cardiac testing is indicated unless he has active cardiac conditions or poor functional capacity. 1, 2

Step 1: Rule Out Active Cardiac Conditions

First, confirm this patient does NOT have any of the following active cardiac conditions that would mandate stopping or delaying surgery 1, 2:

• Unstable angina or severe angina (CCS Class III or IV) 1, 2
• Recent myocardial infarction (within 30 days) 1, 2
• Decompensated heart failure (NYHA Class IV, worsening symptoms, or new-onset heart failure) 1, 2
• Significant arrhythmias (high-grade AV block, symptomatic ventricular arrhythmias, uncontrolled supraventricular arrhythmias) 1, 2
• Severe valvular disease (severe aortic stenosis, symptomatic mitral stenosis) 1, 2

Since the physical exam shows normal S1/S2 with no murmurs or clicks, severe valvular disease is unlikely. 3

Step 2: Assess Functional Capacity

The critical determinant is whether this patient can achieve ≥4 METs of activity without cardiac symptoms. 1, 3, 2

• If he can climb two flights of stairs, walk up a hill, or perform moderate household work without significant dyspnea or chest discomfort, he has adequate functional capacity and requires no further testing. 1, 3
• Patients with good functional capacity (≥4 METs) generally have low perioperative risk even with multiple cardiac risk factors. 1, 3

Step 3: Apply Risk Stratification

Using the Revised Cardiac Risk Index (RCRI), this patient has at least 2-3 risk factors 1, 4:

• High-risk surgery (assuming vascular or major orthopedic procedure)
• Known coronary artery disease
• Hypertension

However, the 2014 ACC/AHA guidelines emphasize that additional cardiac testing should ONLY be ordered if results will change the surgical procedure, alter medical therapy/monitoring, or lead to postponement until cardiac stabilization. 1, 3, 2

Why NOT to Order Additional Testing

Exercise stress testing, echocardiography, or additional ECG are NOT indicated because: 1, 2

• Stress testing does not predict which patients will benefit from preoperative revascularization and primarily delays surgery by 2-3 weeks without improving outcomes. 4, 5
• Resting echocardiography to assess left ventricular function is not a consistent predictor of perioperative ischemic events in patients without current or poorly controlled heart failure. 1
• The ECG already shows LVH, which is expected given his hypertension history, and repeating it adds no value. 1
• Preoperative coronary revascularization does not decrease MI or death rates at 1 month or 6 years in patients undergoing noncardiac surgery. 4

Recommended Management: Optimize Medical Therapy

Instead of testing, focus on perioperative medical optimization: 1, 4

Beta-Blocker Therapy

• If not already on a beta-blocker, initiate low-dose therapy (e.g., bisoprolol 2.5-5 mg daily or metoprolol) ideally 30 days before surgery, but at minimum 2 days preoperatively. 1, 4
• Titrate to target heart rate of 60-70 bpm while maintaining systolic blood pressure >100 mmHg. 1
• Continue beta-blocker therapy perioperatively—abrupt discontinuation in patients with CAD can precipitate severe angina, MI, or ventricular arrhythmias. 6
• Critical caveat: Avoid aggressive beta-blockade without proper titration, as this increases stroke and death risk. 4

Statin Therapy

• Start or continue high-dose statin therapy (e.g., atorvastatin 80 mg or fluvastatin 80 mg daily), ideally 30 days before surgery. 4
• Statins sharply decrease perioperative MI, stroke, and death. 4

Hypertension Management

• Continue all antihypertensive medications through the perioperative period. 1
• Stage 3 hypertension (≥180/110 mmHg) should be controlled before elective surgery. 1

Antiplatelet Therapy

• Continue aspirin perioperatively unless the bleeding risk of the specific surgical procedure outweighs thrombotic risk. 1

Common Pitfalls to Avoid

• Never use the phrase "cleared for surgery" in your consultation note—this oversimplifies the nuanced cardiovascular risk assessment and fails to communicate specific recommendations. 1, 3, 2
• Avoid ordering tests that won't change management—redundant testing delays surgery without improving outcomes. 1, 3, 2
• Don't routinely withdraw beta-blockers before surgery—this increases cardiac risk in patients with CAD. 6
• Don't pursue preoperative coronary revascularization solely to "get the patient through surgery"—this doesn't improve perioperative outcomes. 1, 4, 7

Documentation and Communication

Your consultation note should clearly state: 1, 3, 2

• The patient's cardiovascular status and whether he is in optimal medical condition within the context of his surgical illness
• Specific medication recommendations (beta-blocker initiation/continuation, statin therapy, antihypertensive management)
• Any need for enhanced perioperative monitoring
• Direct communication with the surgeon and anesthesiologist regarding perioperative management

The answer is: Nothing else—proceed to surgery with optimized medical management. 1, 2