What is the next step in investigation for a patient with multiple cardiovascular (CVS) co-morbidities, good functional capacity of ≥4 Metabolic Equivalents (METs), recent lacunar stroke, and elevated revised cardiac risk score, who is planning for elective cataract surgery?

Proceed with Surgery (Option A)

For this patient with good functional capacity ≥4 METs undergoing elective cataract surgery, proceed directly to surgery without additional cardiac testing. 1

Rationale Based on Surgical Risk Classification

Cataract Surgery is Low-Risk

• Cataract surgery is classified as a low-risk procedure with combined morbidity and mortality <1%, even in high-risk patients. 1, 2
• For low-risk surgery, patients should proceed to the planned operation regardless of clinical risk factors or cardiac history. 1
• The ACC/AHA guidelines explicitly state that interventions based on cardiovascular testing in stable patients undergoing low-risk surgery would rarely result in a change in management. 1

Good Functional Capacity Overrides Other Risk Factors

• Patients with functional capacity ≥4 METs can proceed to surgery without further cardiovascular evaluation, as management is rarely changed by additional testing in this population. 1, 3
• The ability to achieve ≥4 METs indicates adequate cardiac reserve and is a reliable predictor of low perioperative cardiac risk. 1
• Even with multiple cardiovascular comorbidities and elevated RCRI score, excellent functional capacity (≥4 METs) is reasonable justification to forgo further exercise or stress testing and proceed directly to surgery. 1

Why the Other Options Are Not Indicated

Transthoracic Echocardiogram (Option B) - 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 worsening heart failure with change in clinical status. 1
• This patient has good functional capacity, which argues against clinically significant cardiac dysfunction requiring echocardiographic assessment. 1

NT-proBNP (Option C) - Not Indicated

• The European Society of Cardiology recommends considering NT-proBNP only for high-risk patients undergoing major noncardiac surgery, not low-risk procedures like cataract surgery. 4
• Routine biomarker sampling is not recommended as it does not change immediate management for low-risk surgery. 4
• NT-proBNP might be considered for vascular or other high-risk surgeries, but cataract surgery does not meet this threshold. 4

CT Coronary Angiogram (Option D) - Not Indicated

• Routine preoperative coronary angiography is not recommended (Class III: No Benefit). 1
• Coronary imaging is reserved for patients with active cardiac conditions (unstable angina, recent MI with residual ischemia) requiring evaluation before surgery. 1
• This patient's recent lacunar stroke does not constitute an active cardiac condition requiring coronary evaluation. 1

Addressing the Recent Lacunar Stroke

Lacunar Stroke Does Not Change Management

• Lacunar clinical presentations and lacunar infarcts make cardioembolic origin unlikely. 5
• Lacunar strokes typically result from small vessel disease rather than cardiac embolism, so cardiac imaging (echo or angiography) would have low diagnostic yield. 5, 6
• While lacunar stroke patients may have cardiac risk factors for long-term prognosis, this does not mandate preoperative cardiac testing for low-risk surgery. 6, 7

Elevated RCRI in Context of Low-Risk Surgery

• The Revised Cardiac Risk Index is validated for intermediate- and high-risk surgeries, not low-risk procedures. 1, 2
• For cataract surgery specifically, no preoperative cardiac evaluation is needed regardless of RCRI score or renal function. 2
• The surgical risk classification supersedes individual patient risk factors when determining need for preoperative testing. 1

Common Pitfalls to Avoid

• Do not reflexively order cardiac testing based on patient comorbidities alone without considering the surgical risk. 2
• Avoid the misconception that elevated RCRI automatically mandates cardiac workup—this only applies to intermediate- or high-risk surgeries. 1, 2
• Do not confuse lacunar stroke with cardioembolic stroke; the former does not typically warrant cardiac source evaluation unless other features suggest cardioembolism. 5, 6
• Functional capacity ≥4 METs is the critical threshold—patients meeting this can proceed to surgery even with multiple cardiac risk factors. 1, 3

Perioperative Management Recommendations

• Ensure guideline-directed medical therapy (GDMT) is optimized, including appropriate antiplatelet therapy for recent stroke and management of cardiovascular risk factors. 1
• Consider perioperative heart rate control with beta blockade if the patient has known coronary disease or multiple clinical risk factors, though this is less critical for low-risk surgery. 1
• No delay in surgery is warranted for additional cardiac testing. 1, 2