What questions should be asked during a preoperative cardiac risk assessment to evaluate a patient's medical history and current symptoms?

Preoperative Cardiac Risk Assessment: Essential Questions

The preoperative cardiac history must systematically identify active cardiac conditions that mandate surgery postponement, assess functional capacity through specific activity questions, and document all cardiovascular risk factors and medications. 1

Active Cardiac Conditions Requiring Immediate Identification

Ask directly about these conditions that absolutely require evaluation and treatment before proceeding:

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

Functional Capacity Assessment (Critical for Risk Stratification)

Ask these specific activity-based questions to determine metabolic equivalent (MET) capacity:

• 1 MET activities: "Can you take care of yourself—eat, dress, use the toilet independently? Can you walk around inside your house?" 1
• 4 MET activities (key threshold): "Can you climb a flight of stairs without stopping? Can you walk up a hill? Can you do heavy housework like scrubbing floors or moving furniture? Can you play golf, bowl, or play doubles tennis?" 1
• >10 MET activities: "Can you run a short distance? Can you participate in strenuous sports like swimming, singles tennis, basketball, or skiing?" 1

Inability to achieve ≥4 METs indicates poor functional capacity and warrants further evaluation in patients with clinical risk factors. 1, 2, 3

Cardiovascular Disease History

Document these specific conditions:

• Prior coronary events: "Have you ever had a heart attack? When? Have you had stents or bypass surgery? When?" 1
• Angina history: "Do you get chest pain, pressure, or tightness with exertion? Does it go away with rest? Do you take nitroglycerin?" 1
• Heart failure: "Have you been told you have a weak heart or heart failure? Have you been hospitalized for fluid in your lungs?" 1
• Arrhythmias: "Do you have atrial fibrillation or other irregular heartbeat? Do you have a pacemaker or defibrillator implanted?" 1
• Valvular disease: "Have you been told you have a leaky or tight heart valve?" 1

Cardiovascular Risk Factors (Revised Cardiac Risk Index Components)

Systematically ask about:

• Diabetes mellitus: "Do you have diabetes? Do you take insulin?" (insulin-requiring diabetes is higher risk) 1, 2
• Renal insufficiency: "Do you have kidney disease? What is your creatinine level? Are you on dialysis?" 1, 2
• Cerebrovascular disease: "Have you had a stroke or TIA (mini-stroke)?" 1, 2
• Peripheral vascular disease: "Do you get leg pain when walking? Have you had surgery on the arteries in your legs?" 1
• Hypertension: "Do you have high blood pressure? What are your typical readings?" 1
• Hyperlipidemia: "Do you have high cholesterol?" 1

Complete Medication History (Exact Doses Required)

Document precisely:

• Beta-blockers: Name and exact dose (critical for perioperative continuation) 1, 4
• Antiplatelet agents: "Do you take aspirin, clopidogrel (Plavix), or other blood thinners? What dose? When did you last take it?" 1, 4
• Anticoagulants: "Do you take warfarin, apixaban, rivaroxaban, or other anticoagulants?" 1
• ACE inhibitors/ARBs: Name and dose (may need to be held morning of surgery) 4, 2
• Diuretics: Type and dose 4, 2
• Statins: Name and dose 4, 2
• Antiarrhythmics: Any medications for heart rhythm 1
• Nitrates: "Do you take nitroglycerin? How often?" 1
• Herbal supplements, over-the-counter medications, and illicit drugs: Document all 1

Associated Comorbidities

• Pulmonary disease: "Do you have COPD, asthma, or sleep apnea? Do you use a CPAP machine?" 1, 2
• Smoking history: "Do you smoke? How many packs per day? For how many years?" 1
• Alcohol use: "How many drinks per week?" 1

Recent Symptom Changes

In patients with known cardiac disease, any recent change in symptoms is critical: "Have your symptoms gotten worse recently? Are you having more chest pain, shortness of breath, or swelling than usual?" 1

Orthostatic Symptoms

"Do you get dizzy or lightheaded when standing up quickly?" (important for patients with pacemakers/ICDs and those on antihypertensives) 1

Common Pitfalls to Avoid

• Do not ask vague questions like "Do you have heart problems?"—be specific about each condition 1, 2
• Do not accept "I can't exercise because of my arthritis" without probing further about what activities they can actually perform 1
• Do not forget to ask about pacemakers/ICDs—these require specific perioperative management 1
• Do not overlook recent symptom changes in patients with known cardiac disease—this may indicate instability 1
• Do not fail to document exact medication doses—this is essential for perioperative management 1, 4