Would you recommend cardiac clearance for an elderly female patient with a history of rheumatoid arthritis (RA) and hypertension, who is on anti-hypertensive medications, prior to undergoing a total knee replacement?

Cardiac Clearance for Elderly Female with Hypertension and Rheumatoid Arthritis Undergoing Total Knee Replacement

Formal cardiac clearance is recommended for this patient, focusing on identifying active cardiac conditions and assessing functional capacity, rather than simply providing routine "clearance for surgery." 1

Why Cardiac Evaluation is Indicated

This patient meets multiple criteria requiring preoperative cardiac assessment:

• Age and hypertension are independent risk factors that warrant cardiac evaluation before orthopedic surgery 2
• Rheumatoid arthritis patients have significantly elevated cardiovascular risk, with hypertension present in approximately 70% of RA patients and often inadequately controlled 3
• The combination of RA and hypertension creates synergistic cardiovascular risk through chronic inflammation and endothelial dysfunction 4, 5
• Total knee arthroplasty in elderly patients carries higher perioperative cardiac complications, including atrial fibrillation, atrial flutter, and increased mortality 6, 7

Essential Components of the Cardiac Assessment

Active Cardiac Conditions to Exclude

The American College of Cardiology requires evaluation for serious conditions before proceeding 1:

• Unstable coronary syndromes (unstable angina, recent MI within 30 days)
• Decompensated heart failure (NYHA class IV, new-onset or worsening HF)
• Significant arrhythmias (high-grade AV block, symptomatic ventricular arrhythmias, uncontrolled supraventricular arrhythmias)
• Severe valvular disease (severe aortic stenosis, symptomatic mitral stenosis)

Functional Capacity Assessment

Determine if the patient can perform activities requiring ≥4 METs (climbing two flights of stairs or walking four blocks without symptoms), as this correlates with lower perioperative risk 1, 8. Patients with poor functional capacity and cardiac risk factors require more extensive evaluation.

Risk Stratification

Calculate the Lee (Revised Cardiac Risk Index) score 8:

• If score ≥2 with poor functional capacity, refer to cardiology for further evaluation
• This patient likely scores at least 1 point for hypertension requiring medication

Required Testing

Obtain a current ECG to evaluate for ischemic changes, arrhythmias, or conduction abnormalities 8. The American College of Cardiology advises that preoperative tests should only be ordered if results will change management, surgical approach, or lead to postponement until cardiac stabilization 1.

Special Considerations for RA Patients

Cardiovascular Risk in Rheumatoid Arthritis

• RA patients have excessive cardiovascular morbidity and mortality independent of traditional risk factors 2
• Hypertension in RA is often under-diagnosed and under-treated, with only 21.8% of treated patients achieving optimal control 3
• The combination of chronic inflammation, endothelial dysfunction, and hypertension creates a "mutually reinforcing triad" that significantly amplifies cardiovascular risk 5

Medication Review

Document all current medications including anti-hypertensives and RA treatments 1. The 2022 ACR/AAHKS guideline addresses perioperative management of antirheumatic medications but explicitly states it does not cover perioperative cardiac assessment, as this requires separate focused evaluation 2.

Perioperative Risks to Anticipate

Based on data from elderly TKA patients 7:

• Increased incidence of cardiac arrhythmias (particularly atrial fibrillation/flutter)
• Higher rates of postoperative confusion (which can mask cardiac symptoms)
• Longer hospital stays and increased mortality compared to younger patients
• Blood transfusion requirements may be higher, which can stress the cardiovascular system

Critical Communication Points

Avoid using the phrase "cleared for surgery" in consultation notes 1. Instead, provide specific documentation of:

• Cardiac conditions identified or excluded
• Functional capacity assessment results
• Specific recommendations for perioperative management
• Any conditions requiring optimization before surgery

Ensure clear communication between the consultant, surgeon, anesthesiologist, and rheumatologist regarding the patient's cardiac status and perioperative plan 1.

Common Pitfalls to Avoid

• Do not order tests that will not change management decisions 1
• Do not focus solely on short-term perioperative risk without addressing long-term cardiac risk management, as the perioperative evaluation provides an opportunity for implementing cardiac risk reduction strategies 1
• Do not assume hypertension is well-controlled in RA patients without verification, as control rates are poor even among treated patients 3
• Do not underestimate the additive cardiovascular risk from the combination of RA, chronic inflammation, and hypertension 4, 5