What cardiovascular evaluation and testing are needed for a female patient with hypertension (HTN), factor V Leiden, depression, and morbid obesity, who is being considered for bariatric surgery and has a normal electrocardiogram (EKG) and no reported cardiac symptoms?

Cardiovascular Testing for Bariatric Surgery Clearance

No additional cardiovascular testing is needed from cardiology for this patient beyond the normal EKG already obtained. 1

Rationale Based on Current Risk Profile

Your assessment is appropriate. This patient meets criteria for cardiac clearance without further testing based on the following:

Completed Adequate Baseline Evaluation

• A 12-lead EKG has been obtained and is normal, which satisfies the American Heart Association's recommendation for all severely obese patients with at least one CHD risk factor (hypertension qualifies) 1
• Comprehensive history and physical examination have been performed with documentation of no cardiac symptoms, no chest pain, no dyspnea, and good functional capacity 1
• Revised Cardiac Risk Index score of 1 indicates low perioperative risk (1.1% risk of major adverse cardiac events) [@User provided]

When Additional Testing Would Be Indicated

The American Heart Association specifies that severely obese patients require additional noninvasive testing only if they have ≥3 CHD risk factors OR diagnosed CHD, AND only if results would change management [@4@, 1]

This patient has:

• Only 1 traditional CHD risk factor (hypertension) [@2@, 1]
• No diagnosed coronary heart disease [@User provided]
• No cardiac symptoms (no chest pain, dyspnea, or functional limitation) [@User provided]
• Normal EKG without concerning features [@User provided]

Additional Considerations Already Addressed

Chest radiograph recommendation: The American Heart Association recommends obtaining a chest radiograph (preferably PA and lateral) on all severely obese patients under consideration for surgery to evaluate for undiagnosed heart failure, cardiac chamber enlargement, or pulmonary hypertension 1. While not explicitly documented in your note, this would be reasonable to obtain if not already done, though it is typically coordinated by the surgical team rather than cardiology.

Factor V Leiden consideration: This thrombophilia increases perioperative VTE risk but does not necessitate additional cardiac testing. Perioperative anticoagulation protocols should be addressed by the surgical team 1

History of preeclampsia: While this indicates endothelial dysfunction history, it occurred with only the first pregnancy and does not change the current cardiac risk stratification in an asymptomatic patient with normal EKG [@General medical knowledge]

Common Pitfalls to Avoid

• Do not order routine stress testing or echocardiography in asymptomatic patients with <3 risk factors, as this represents low-value care and may lead to false positives requiring unnecessary interventions [@4@, 1]
• Physical examination underestimates cardiac pathology in obesity, but in the absence of symptoms or multiple risk factors, imaging is not indicated [@3@, @6@]
• Morbid obesity alone is not an indication for advanced cardiac testing when functional capacity is preserved and symptoms are absent [@4