What preoperative cardiac evaluation is recommended for a patient with hypertension, coronary artery disease, and a history of smoking?

Preoperative Cardiac Evaluation for Patients with HTN, CAD, and Smoking History

A preoperative 12-lead EKG is mandatory for this patient, while routine echocardiography is not indicated unless there are specific clinical concerns such as symptoms of heart failure, suspected valvular disease, or poor functional capacity. 1, 2

EKG Indication - Clear Recommendation

Your patient meets multiple criteria that mandate preoperative EKG:

• Known coronary artery disease automatically qualifies for preoperative EKG when undergoing intermediate- or high-risk surgery 1, 2
• Hypertension is recognized as a cardiovascular risk factor requiring EKG for intermediate-risk procedures 1
• Smoking history is specifically listed as an indication to consider preoperative EKG 1
• The combination of multiple cardiovascular risk factors (HTN + CAD + smoking) makes EKG reasonable even for intermediate-risk surgery 1, 2

The ACC/AHA guidelines are explicit: patients with known heart disease, peripheral vascular disease, or cerebrovascular disease undergoing intermediate- or high-risk surgery should have a preoperative EKG to establish baseline cardiac status and guide perioperative management 1, 2. This is a Class I recommendation (strongest level). 1

Echocardiography - Generally Not Indicated

Routine preoperative echocardiography is not recommended for this patient unless specific clinical indicators are present. 3

Echocardiography should be reserved for:

• Symptomatic patients with suspected heart failure (dyspnea, orthopnea, paroxysmal nocturnal dyspnea, elevated jugular venous pressure) 1
• Suspected severe valvular disease (particularly aortic stenosis with mean gradient >40 mmHg or symptomatic mitral stenosis) 1
• Acute heart failure or cardiomyopathy 3
• Poor functional capacity (<4 METs) with unclear etiology 2

The literature does not support routine echocardiography for preoperative cardiac risk assessment in stable patients with known CAD 3. A 1998 review in Der Anaesthesist explicitly states that routine echocardiography for assessing perioperative cardiac risk cannot be supported 3.

Risk Stratification Approach

Determine the surgical risk category first 2:

• High-risk surgery (>5% cardiac risk): Major vascular, aortic surgery, prolonged procedures with large fluid shifts 1
• Intermediate-risk surgery (1-5% cardiac risk): Carotid endarterectomy, head/neck, intraperitoneal, intrathoracic, orthopedic, prostate surgery 1
• Low-risk surgery (<1% cardiac risk): Endoscopic, superficial, cataract, breast procedures 1

For intermediate- or high-risk surgery, this patient with known CAD absolutely requires preoperative EKG 1, 2. For low-risk surgery, EKG may still be reasonable given the multiple risk factors, though not absolutely mandatory 2.

Functional Capacity Assessment

Assess the patient's functional capacity using metabolic equivalents (METs) 1, 2:

• Excellent capacity (>10 METs): Can run, do heavy work - surgery can generally proceed with just EKG 2
• Moderate capacity (4-10 METs): Can climb stairs, walk briskly - EKG sufficient for most cases 1
• Poor capacity (<4 METs): Cannot walk one block or climb one flight - warrants additional evaluation beyond EKG 2

If your patient has poor functional capacity despite optimal medical management, consider stress testing or cardiology consultation before proceeding 1, 4. However, recent evidence suggests stress testing does not reliably predict MI or death and may unnecessarily delay surgery 4.

Additional Preoperative Considerations

Optimize medical management rather than pursuing invasive testing 4:

• Beta-blockers: Should be continued or initiated (bisoprolol 2.5-5 mg daily started ideally 1 month before surgery, titrated to heart rate <70 bpm and systolic BP >120 mmHg) 1, 4
• Statins: Start long-acting statin (e.g., fluvastatin 80 mg daily) ideally 30 days before surgery - this sharply decreases MI, stroke, and death perioperatively 4
• Hypertension control: Target <130/80 mmHg; Stage 3 hypertension (≥180/110 mmHg) must be controlled before elective surgery 1, 5
• Smoking cessation: Strongly advisable to reduce postoperative respiratory complications 1

Common Pitfalls to Avoid

• Do not order routine echocardiography without specific clinical indication - this increases costs without improving outcomes 3
• Do not delay surgery for routine stress testing in stable patients with 0-2 risk factors - stress testing is not predictive of MI or death and delays surgery up to 3 weeks 4
• Do not pursue coronary revascularization solely to "clear" the patient for noncardiac surgery - revascularization does not decrease MI or death rates at 1 month or 6 years 4
• Do not start high-dose beta-blockers acutely before surgery - improper timing and dosage may increase stroke and death rates 4
• Do not forget to compare with previous EKGs when available - chronic findings may be misinterpreted as acute 2

Algorithm Summary

1. Obtain preoperative 12-lead EKG (mandatory for this patient) 1, 2
2. Assess functional capacity using METs 1, 2
3. Determine surgical risk category (low/intermediate/high) 1
4. Optimize medical therapy: Continue/start beta-blocker and statin, control hypertension, encourage smoking cessation 1, 5, 4
5. Consider echocardiography only if: Symptoms of heart failure, suspected valvular disease, or poor functional capacity with unclear cause 3
6. Reserve stress testing for: Patients with ≥3 risk factors when surgery can be delayed 30 days for medical optimization 4
7. Avoid routine coronary angiography unless patient has unstable angina or acute coronary syndrome 1, 4