What preoperative evaluation is recommended for a 65-year-old male with hypertension, occasional smoking, left ventricular hypertrophy (LVH), and good functional capacity, who is taking a statin and antihypertensive medication, and is scheduled for a routine cystoscopy?

Preoperative Evaluation for Routine Cystoscopy in a 65-Year-Old with Hypertension and LVH

No additional testing is needed—proceed directly to surgery with continuation of current medications. 1, 2

Risk Stratification

This patient is undergoing a low-risk procedure (cystoscopy), which carries less than 1% risk of major adverse cardiac events (MACE). 2 The ACC/AHA guidelines explicitly state that routine preoperative ECGs, laboratory tests, and cardiac stress testing are not indicated for asymptomatic patients undergoing low-risk surgical procedures. 1, 2

Functional Capacity Assessment

The critical determining factor here is functional capacity. This patient:

• Plays on a tennis team (clearly >4 METs activity)
• Has excellent functional capacity (>10 METs)
• Is asymptomatic with normal cardiac examination 1

Patients with excellent functional capacity (>10 METs) can proceed directly to surgery regardless of clinical risk factors, including the presence of LVH. 1, 3 The ACC/AHA guidelines are explicit that for patients with elevated risk and excellent functional capacity, it is reasonable to forgo further exercise testing. 1

Why Each Test is NOT Indicated

Repeat EKG: Not Needed

• The old EKG showing LVH is sufficient information 1
• Preoperative ECGs are not indicated in asymptomatic persons undergoing low-risk surgical procedures 1
• The optimal interval between ECG and elective surgery for stable patients is 1-3 months, but this patient is stable and the procedure is low-risk 1

Exercise Stress Test: Not Indicated

• No test should be performed unless it is likely to influence patient treatment 1, 2
• Exercise testing is only considered for patients with ≥2 clinical risk factors AND poor functional capacity (<4 METs) undergoing intermediate or high-risk surgery 1
• This patient has excellent functional capacity and is undergoing low-risk surgery 2

Echocardiogram: Not Indicated

• Routine preoperative evaluation of LV function is not recommended (Class III: No Benefit) 1
• Echocardiography is reasonable only for patients with dyspnea of unknown origin or heart failure with worsening symptoms 1
• This patient is asymptomatic with normal cardiac examination and excellent functional capacity 1

Perioperative Management

Continue Current Medications

• Antihypertensive medications should be continued during the perioperative period 1
• Statins should be continued (Class I recommendation) 3
• Particular care should be taken to avoid withdrawal of beta blockers if the patient is taking one, due to potential rebound 1

Blood Pressure Management

• Stage 1 or 2 hypertension (systolic <180 mmHg, diastolic <110 mmHg) is not an independent risk factor for perioperative cardiovascular complications 1
• If blood pressure is mildly elevated on the day of surgery, there is no evidence that delaying surgery is beneficial 1

Clinical Context of LVH

While the old EKG shows LVH, this finding does not change management in this scenario because:

• LVH is a marker of chronic hypertension but the patient is currently treated and stable 1, 4
• The patient's excellent functional capacity demonstrates adequate cardiovascular reserve 1, 3
• LVH alone does not warrant additional preoperative testing in asymptomatic patients with good functional capacity undergoing low-risk procedures 1

Common Pitfalls to Avoid

• Do not order "routine" preoperative testing for low-risk procedures—this is explicitly discouraged by guidelines and does not improve outcomes 1, 2
• Do not confuse the presence of risk factors (hypertension, LVH) with the need for testing—functional capacity and surgical risk category are the primary determinants 1, 3
• Do not delay surgery for cardiac workup in stable patients with good functional capacity—the perioperative evaluation is not about "medical clearance" but risk assessment 1