What are the steps for cardiac clearance in a patient with potential cardiac risk factors?

Step-by-Step Cardiac Clearance

Cardiac clearance requires a systematic algorithmic approach that stratifies risk, determines need for testing, and provides explicit perioperative management recommendations—never simply state "cleared for surgery." 1, 2

Step 1: Determine Surgical Urgency

• Emergency surgery: Proceed immediately with intraoperative monitoring and management based on known cardiac conditions; formal clearance is not feasible 1
• Urgent surgery: Limited time for optimization; focus on identifying active cardiac conditions requiring immediate treatment 1
• Elective surgery: Full evaluation pathway applies 1

Step 2: Identify Active Cardiac Conditions Requiring Delay

If any of these conditions are present, delay elective surgery until evaluated and stabilized: 1

• Unstable or severe angina (CCS class III-IV) 1
• Recent MI within 30 days or acute MI within 7 days 1
• Decompensated heart failure (NYHA class IV, new-onset, or worsening) 1
• Significant arrhythmias: high-grade AV block, Mobitz II or third-degree heart block, symptomatic ventricular arrhythmias, uncontrolled atrial fibrillation (HR >100 bpm at rest), symptomatic bradycardia 1
• Severe valvular disease: severe aortic stenosis (mean gradient >40 mmHg, valve area <1.0 cm², or symptomatic) or symptomatic mitral stenosis 1

If active conditions exist, refer for cardiology evaluation and treatment before proceeding. 1

Step 3: Stratify Surgical Risk

Categorize the planned procedure: 1, 2

• Low-risk (<1% cardiac event rate): Endoscopic procedures, cataract surgery, breast surgery, ambulatory surgery—proceed without further testing 1
• Intermediate-risk: Intraperitoneal, intrathoracic, orthopedic, prostate surgery 1
• High-risk (>5% cardiac event rate): Major vascular surgery (aortic, peripheral vascular), prolonged procedures with large fluid shifts 1

For low-risk surgery, proceed regardless of patient risk factors. 1

Step 4: Calculate Patient-Specific Cardiac Risk

Use the Revised Cardiac Risk Index (RCRI) or ACS NSQIP calculator: 1, 2

RCRI assigns 1 point for each: 1, 2

• High-risk surgery (vascular, intraperitoneal, intrathoracic)
• History of ischemic heart disease (prior MI, positive stress test, current angina, pathologic Q waves)
• History of heart failure
• History of cerebrovascular disease (stroke or TIA)
• Insulin-dependent diabetes mellitus
• Preoperative creatinine >2 mg/dL

Risk stratification: 1, 2

• 0 points: <1% risk of major adverse cardiovascular events (MACE)
• 1 point: 1% risk
• 2 points: 2-7% risk
• ≥3 points: >9% risk

Additional risk factors to document: 1, 2

• Age ≥60 years
• Hypertension
• Hyperlipidemia
• Smoking status
• Obesity
• Peripheral arterial disease
• Chronic kidney disease

Step 5: Assess Functional Capacity

Determine metabolic equivalent (MET) capacity: 1, 2

• ≥4 METs (good functional capacity): Can climb 2 flights of stairs, walk up a hill, run a short distance, do heavy housework—proceed to surgery without testing 1, 3
• <4 METs (poor functional capacity): Cannot perform above activities—consider testing if elevated risk 1, 3
• Unknown functional capacity: Consider exercise stress testing to objectively assess 1

If functional capacity is ≥4 METs, proceed to surgery even with elevated RCRI. 1

Step 6: Determine Need for Preoperative Testing

Testing is indicated ONLY if results will change management. 1, 2

12-Lead ECG Indications:

• Known cardiovascular disease, arrhythmias, peripheral arterial disease, or cerebrovascular disease undergoing intermediate or high-risk surgery 1, 2
• ≥1 clinical risk factor undergoing vascular surgery 1, 2
• NOT indicated for asymptomatic patients undergoing low-risk surgery 1

Echocardiography Indications:

• Suspected moderate-to-severe valvular stenosis or regurgitation without echo in past year 1, 2
• Current or poorly controlled heart failure 1, 2
• Dyspnea of unknown origin 1, 2
• Suspected new or worsening ventricular dysfunction 1, 2
• NOT routinely indicated for preoperative assessment 1

Stress Testing Indications:

Only perform if: 1, 2

• Patient has poor or unknown functional capacity (<4 METs) AND
• Elevated calculated risk (RCRI ≥1 or >1% MACE risk) AND
• Undergoing intermediate or high-risk surgery AND
• Results would change decision to proceed with surgery or alter perioperative management (e.g., willingness to undergo revascularization, change anesthesia approach, increase monitoring)

Do NOT perform stress testing if: 1

• Patient has good functional capacity (≥4 METs)
• Undergoing low-risk surgery
• Results will not change management

Step 7: Preoperative Medication Management

Continue Perioperatively:

• Statins: Continue in all patients with atherosclerotic disease; consider initiating in patients undergoing vascular surgery 1, 2, 3
• Beta-blockers: Continue if already taking; do NOT start high-dose beta-blockers 2-4 hours before surgery (increases stroke and mortality risk) 1, 3
• ACE inhibitors/ARBs: Continue in patients with heart failure; may hold morning of surgery if hypotension risk 1, 2
• Aspirin: Continue in patients with coronary stents; otherwise, routine perioperative aspirin does not reduce events but increases bleeding 3

Dual Antiplatelet Therapy (DAPT) After Stenting:

• Bare metal stent: Delay elective surgery ≥6 weeks; continue DAPT 2
• Drug-eluting stent: Delay elective surgery ≥12 months; continue DAPT 2
• If surgery cannot be delayed, continue aspirin and discuss with cardiologist regarding P2Y12 inhibitor 2

Anticoagulation:

• Develop bridging plan based on thrombotic risk and bleeding risk of procedure 2

Step 8: Provide Explicit Recommendations

Your note must include: 2

Risk Assessment Statement:

"Patient is at [LOW/INTERMEDIATE/HIGH] risk for perioperative MACE based on [specific RCRI score, functional capacity, surgical risk category]" 2

Specific Perioperative Recommendations:

• Which medications to continue and which to hold 2
• Level of postoperative monitoring (floor vs. telemetry vs. ICU) 2
• Consider postoperative troponin surveillance in elevated-risk patients 2
• Parameters for seeking immediate cardiac consultation postoperatively 2

Long-Term Risk Reduction:

• Smoking cessation 1, 2
• Optimization of hypertension, diabetes, hyperlipidemia 1, 2
• Initiation of guideline-directed medical therapy for coronary disease or heart failure 2
• Follow-up plan with cardiology if indicated 2

Critical Pitfalls to Avoid

• Never use the phrase "cleared for surgery"—this provides no actionable information 1, 2
• Do not order unnecessary tests—testing should only be performed if results will change management 1, 2
• Do not routinely start high-dose beta-blockers immediately preoperatively—this increases stroke and mortality 1, 3
• Do not perform routine coronary revascularization before noncardiac surgery—this does not reduce perioperative risk 3
• Do not miss the opportunity for long-term cardiovascular risk reduction—address modifiable risk factors 1, 2
• Ensure direct communication with surgeon and anesthesiologist—written recommendations alone are insufficient 1, 2