What components should a primary care provider evaluate during a pre‑operative appointment?

Pre-Operative Assessment Components for Primary Care Providers

Primary care providers should systematically evaluate cardiovascular stability, functional capacity, active cardiac conditions, medication optimization, pulmonary risk factors, and surgical risk stratification—not simply provide "medical clearance." 1, 2

Core Assessment Framework

Active Cardiac Conditions (Absolute Contraindications to Elective Surgery)

The following conditions mandate postponement of elective surgery until evaluated and treated 1, 2, 3:

• Unstable or severe angina (CCS Class III-IV) 1, 2, 3
• Recent myocardial infarction (within 30 days, but >7 days from surgery date) 1, 2, 3
• Decompensated heart failure (NYHA Class IV, new-onset, or worsening symptoms) 1, 2, 3
• Significant arrhythmias: high-grade AV block, symptomatic ventricular arrhythmias, newly recognized ventricular tachycardia, uncontrolled atrial fibrillation (>100 bpm), symptomatic bradycardia 1, 2, 3
• Severe valvular disease (severe aortic stenosis with mean gradient >40 mmHg or valve area <1.0 cm², symptomatic mitral stenosis) 1, 2, 3

Cardiovascular History Documentation

Document the exact presence or absence of 2, 4:

• Prior myocardial infarction with timing (especially if within 6 months) 4
• Coronary revascularization (CABG or PCI with stent type and date) 4
• Heart failure with NYHA class and recent decompensation 4
• Pacemaker or ICD presence 4
• Valvular disease (known stenosis/regurgitation, symptomatic status) 4
• Cerebrovascular disease history 2
• Diabetes requiring insulin 2
• Renal insufficiency (creatinine >2 mg/dL) 2

Functional Capacity Assessment

Assess ability to perform 4 METs of activity (climbing 2 flights of stairs, walking up a hill, running a short distance) 2, 4:

• Good functional capacity (≥4 METs): Patients can proceed to intermediate-risk surgery without further cardiac testing, even with multiple risk factors 2
• Poor functional capacity (<4 METs) with clinical risk factors: Requires further cardiac evaluation before intermediate or high-risk surgery 2, 3

Medication History (Exact Drugs and Dosages)

Document and provide specific perioperative recommendations for 2, 4:

• Beta-blockers: Continue perioperatively; abrupt discontinuation risks MI or arrhythmias 2
• Antiplatelet agents (aspirin, clopidogrel): Document and discuss continuation vs. holding with surgeon 2
• ACE inhibitors/ARBs: Hold the morning of surgery to prevent intraoperative hypotension (must document explicitly) 2
• Statins: Continue perioperatively 2
• Antihypertensives: Continue through perioperative period 2
• Diuretics: Document dosing 2
• Anticoagulants: Coordinate bridging plan if applicable 1

Pulmonary Risk Assessment

Screen for conditions that significantly increase postoperative pulmonary complications 4:

• COPD or asthma (document severity, recent exacerbations) 4
• Obstructive sleep apnea: Use specific screening questions (snoring, witnessed apneas, daytime somnolence, CPAP use); document BMI, neck circumference, tonsillar size 2, 4
• Interstitial lung disease (affects candidacy even with adequate spirometry) 4
• Dyspnea (progressive exertional dyspnea, exercise intolerance) 4
• Smoking history (current or former) 4
• Recent pulmonary infections 4
• Baseline oxygen saturation on room air 4

Physical Examination Components

Perform targeted cardiovascular and pulmonary examination 2, 4:

• Blood pressure in both arms 2
• Heart rate and rhythm 2
• Jugular venous pressure 2
• Carotid bruits 2
• Heart murmurs (grade and location) 2
• Peripheral edema 2
• Lung auscultation (wheezes, crackles) 2
• Mallampati score (airway assessment) 2

Surgical Risk Stratification

Determine the cardiac risk of the planned procedure 2:

• Low-risk surgery (<1% cardiac risk): Proceed without further cardiac testing regardless of patient risk factors 2
• Intermediate-risk surgery (1-5% cardiac risk): Proceed if functional capacity ≥4 METs; consider testing if <4 METs with risk factors 2
• High-risk surgery (>5% cardiac risk): Requires careful risk-benefit discussion and possible additional testing 2

Additional Risk Factors

Document factors that increase perioperative complications 1, 4:

• Age ≥65 years (especially ≥70 for elderly-specific assessment) 1, 4
• Functional dependence (inability to perform ADLs) 4
• Weight loss >10% preoperatively 4
• Nutritional status (BMI, serum albumin if available) 4
• Frailty assessment in elderly patients 1
• Cognitive status and delirium risk factors 1

Critical Communication Requirements

What to Document

Never use the phrase "cleared for surgery"—instead, provide 1, 2, 3:

• Cardiovascular stability statement: "Patient's cardiovascular status is stable" or "Patient has active cardiac condition requiring treatment" 2, 3
• Optimal medical condition: "Patient is in optimal medical condition for the planned surgery" or "Recommend optimization of [specific condition]" 2, 3
• Specific medication recommendations: Continue, hold, or adjust specific drugs with exact instructions 2, 3
• Need for enhanced monitoring: ICU vs. floor, telemetry, invasive monitoring 2, 3

Direct Communication

Communicate directly with the surgical and anesthesia teams, not just through documentation 1, 2, 3:

• Discuss cardiovascular stability verbally 2, 3
• Clarify medication management plan 2, 3
• Identify need for additional testing or postponement 2, 3

When to Order Additional Testing

Order preoperative tests ONLY if results will 1, 2, 3:

• Change the surgical procedure 2, 3
• Alter medical therapy or monitoring 2, 3
• Lead to postponement until cardiac condition is stabilized 2, 3

Routine Testing Is NOT Indicated

• Routine laboratory testing does not reduce perioperative morbidity or mortality in asymptomatic patients 1
• Routine ECG is not required for low-risk surgery in asymptomatic patients 1
• Routine chest X-ray is not indicated without specific pulmonary symptoms 5

Directed Testing May Be Appropriate

For patients with severe systemic diseases (poorly controlled hypertension, recent MI, unstable angina, poorly controlled CHF, poorly controlled diabetes, severe COPD), consider preoperative medical evaluation 1

Common Pitfalls to Avoid

• Do not simply "clear" patients—provide a nuanced risk assessment 1, 2, 3
• Do not order tests that won't change management—this wastes resources and delays surgery 1, 2
• Do not delay surgery unnecessarily—balance optimization against risks of surgical delay (e.g., hip fracture, emergency laparotomy) 1
• Do not forget to assess functional capacity—this is often more predictive than testing 2
• Do not overlook medication reconciliation—perioperative medication errors are common and preventable 2

Validity of Pre-Operative Assessment

A pre-operative cardiac evaluation remains valid for 30 days in stable patients 3. The assessment is immediately invalidated by 3:

• Development of any active cardiac condition listed above 3
• Any new or worsening cardiovascular symptoms (chest pain, dyspnea, palpitations) 3
• New arrhythmias or heart failure decompensation 3