What are the main questions to ask a patient with a history of cardiovascular disease, hypertension, diabetes, or respiratory conditions, who is taking various medications, to assess their preoperative clearance?

Main Questions for Preoperative Clearance

The preoperative evaluation must systematically identify active cardiac conditions that mandate stopping surgery, assess functional capacity, and determine medication optimization—not simply "clear" patients for surgery. 1

Critical Questions That Determine Whether Surgery Can Proceed

Active Cardiac Conditions (Surgery Must Be Postponed If Present)

Ask specifically about these conditions that are absolute contraindications to elective surgery 1, 2:

• Unstable or severe angina: "Do you have chest pain at rest or with minimal activity? Has your angina worsened recently?" (CCS Class III or IV) 1, 2
• Recent myocardial infarction: "Have you had a heart attack in the past month?" (defined as >7 days but ≤30 days) 1, 2
• Decompensated heart failure: "Are you short of breath at rest? Can you lie flat without getting short of breath? Have you gained weight or noticed swelling recently?" (NYHA Class IV, worsening or new-onset) 1, 2
• Significant arrhythmias: "Do you have a pacemaker or defibrillator? Have you had episodes of rapid heartbeat, dizziness, or passing out?" 1, 2
• Severe valvular disease: "Do you have a heart murmur? Have you been told you have aortic stenosis or mitral stenosis? Do you get short of breath or dizzy with exertion?" 1, 2

If any of these are present, surgery must be postponed for cardiac evaluation and treatment. 2

Functional Capacity Assessment (Determines Need for Further Testing)

Ask the patient to quantify their exercise tolerance using specific activities 1:

• Less than 4 METs (poor functional capacity): "Can you walk up a flight of stairs or walk uphill? Can you do heavy housework like scrubbing floors or moving furniture?" 1
• 4-10 METs (moderate to good): "Can you run a short distance? Can you play golf, bowl, or play doubles tennis?" 1
• Greater than 10 METs (excellent): "Can you participate in strenuous sports like swimming, singles tennis, or basketball?" 1

Patients who cannot perform 4 METs of activity require further evaluation if they have clinical risk factors. 2, 3

Clinical Risk Factors for Coronary Disease

Document the presence of these modifiable and non-modifiable risk factors 1:

• Coronary artery disease history: "Have you ever had a heart attack, stents, or bypass surgery? Do you have angina?" 1, 4
• Heart failure history: "Have you been told you have a weak heart or heart failure?" 1
• Cerebrovascular disease: "Have you had a stroke or TIA?" 1
• Diabetes requiring insulin: "Do you have diabetes? Do you take insulin?" 1
• Renal insufficiency: "Do you have kidney disease? What is your creatinine level?" 1

Medication History (Critical for Perioperative Management)

Current Cardiac Medications

Document exact medications and dosages 1:

• Beta-blockers: "Do you take metoprolol, atenolol, or carvedilol? What dose?" 1, 2
• Antiplatelet agents: "Do you take aspirin, Plavix (clopidogrel), or other blood thinners?" 2
• Antihypertensives: "What blood pressure medications do you take? ACE inhibitors (lisinopril, enalapril)? ARBs (losartan)?" 1, 2
• Diuretics: "Do you take water pills like furosemide or hydrochlorothiazide?" 1
• Statins: "Do you take cholesterol medications?" 3

Common pitfall: ACE inhibitors and ARBs should be held the morning of surgery to prevent intraoperative hypotension, but this must be documented explicitly. 1

Diabetes Medications

For patients with diabetes, document 1:

• Insulin regimen: "What type of insulin do you use? What are your doses? When do you take it?" 1
• Oral hypoglycemics: "Do you take metformin, sulfonylureas, or SGLT2 inhibitors?" 1
• Recent glucose control: "What have your blood sugars been running? Have you had low blood sugars?" 1

Other Medications

• Herbal supplements: "Do you take any vitamins, supplements, or herbal products?" 1
• Anticoagulants: "Do you take warfarin, Eliquis, Xarelto, or other blood thinners?" 1
• Substance use: "Do you use tobacco, alcohol, marijuana, or other recreational drugs?" 1

Respiratory Conditions (For OSA Screening)

Ask these specific questions to identify obstructive sleep apnea 1:

• Snoring and apnea: "Do you snore loudly? Has anyone witnessed you stop breathing during sleep?" 1
• Sleep disruption: "Do you wake up frequently during the night? Do you wake up gasping or choking?" 1
• Daytime symptoms: "Do you have morning headaches? Are you excessively sleepy during the day?" 1
• CPAP use: "Do you use a CPAP machine? Do you bring it to the hospital?" 1

Document body mass index, neck circumference, and tonsillar size on physical examination. 1

Hypertension Assessment

For patients with hypertension 1, 2:

• Blood pressure control: "What is your usual blood pressure? When was it last checked?" 1, 2
• Stage 3 hypertension (≥180/110 mmHg): "If your blood pressure is this high today, we need to control it before surgery." 1, 2
• Orthostatic symptoms: "Do you get dizzy when you stand up?" 1

Measure blood pressure in both arms during physical examination. 1

Physical Examination Components

Beyond vital signs, specifically assess 1:

• Cardiovascular: Jugular venous pressure, carotid bruits, heart murmurs, peripheral edema 1
• Pulmonary: Lung auscultation for crackles or wheezing 1
• Airway: Mallampati score, neck circumference, tonsillar size (for OSA risk) 1

Surgical Risk Stratification

Determine the cardiac risk of the planned surgery 1, 2:

• Low-risk surgery (<1% cardiac risk): Endoscopic procedures, cataract surgery, breast surgery, ambulatory surgery 1, 2, 3
• Intermediate-risk surgery (1-5% cardiac risk): Intraperitoneal surgery, orthopedic surgery, head/neck surgery 1, 2
• High-risk surgery (>5% cardiac risk): Vascular surgery, major emergency surgery 1, 2

For low-risk surgery, patients can proceed without further cardiac testing regardless of risk factors. 2, 3

Critical Communication Points

Never use the phrase "cleared for surgery"—instead, document 1, 2:

• The patient's cardiovascular stability 2, 4
• Whether the patient is in optimal medical condition within the context of their surgical illness 1, 4
• Specific medication recommendations (continue, hold, or adjust) 2, 3
• Any need for enhanced perioperative monitoring 2

Communicate directly with the surgeon and anesthesiologist, not just through documentation. 1, 2, 4

When to Order Additional Testing

Order preoperative tests ONLY if results will 1, 2, 3, 4:

• Change the surgical procedure performed 1, 2, 3, 4
• Alter medical therapy or monitoring during/after surgery 1, 2, 3, 4
• Lead to postponement until the cardiac condition is stabilized 1, 2, 3, 4

Common pitfall: Avoid reflexive ordering of stress tests, echocardiograms, or cardiac catheterization in stable patients with good functional capacity. 2, 3