Should a 70‑year‑old patient with coronary artery disease, heart failure, hypertension, type 2 diabetes, chronic obstructive pulmonary disease, chronic kidney disease, and chronic warfarin therapy obtain formal pre‑operative clearance before a low‑risk procedure such as cataract surgery?

No Formal Pre‑Operative Clearance Required for Cataract Surgery

For a 70‑year‑old patient with multiple comorbidities undergoing cataract surgery, formal pre‑operative clearance is not required because cataract surgery is classified as low‑risk (<1% cardiac event rate), and routine pre‑operative testing does not improve outcomes in this population. 1, 2

Risk Classification of Cataract Surgery

• Cataract surgery is explicitly categorized as a low‑risk procedure with a combined surgical and patient risk of major adverse cardiac events (death or myocardial infarction) of <1%. 1
• Low‑risk procedures include cataract surgery, superficial procedures, endoscopic procedures, breast surgery, and ambulatory surgery—none of which generally require further pre‑operative cardiac testing. 1
• The ACC/AHA guidelines state that patients undergoing low‑risk surgery should proceed to the planned operation regardless of clinical risk factors or cardiac history, because interventions based on cardiovascular testing in stable patients would rarely change management. 1, 2

Evidence Against Routine Pre‑Operative Testing for Cataract Surgery

• A large randomized controlled trial of more than 19,000 patients undergoing cataract surgery found no difference in outcomes between patients who received routine pre‑operative testing and those who did not. 1
• Abnormal pre‑operative test results did not predict outcomes in cataract surgery patients. 1
• A 2012 Cochrane review reinforced that patients in their usual state of health undergoing cataract surgery do not require pre‑operative testing. 1
• Routine pre‑operative evaluation of left ventricular function is not recommended (Class III: No Benefit) for low‑risk surgery. 2
• Routine pre‑operative coronary angiography is not recommended (Class III: No Benefit) for low‑risk surgery. 2

When to Proceed Directly to Surgery

• Patients with good functional capacity ≥4 METs (able to climb two flights of stairs or walk four blocks without symptoms) undergoing elective low‑risk surgery can proceed directly to surgery without additional cardiac testing. 2
• Even patients with multiple comorbidities (coronary artery disease, heart failure, hypertension, diabetes, COPD, chronic kidney disease, chronic warfarin therapy) should proceed to cataract surgery without formal clearance, as the surgical risk remains <1%. 1, 2
• For low‑risk surgery, patients should proceed regardless of clinical risk factors or cardiac history, because management is rarely changed by additional testing in this population. 2

Exceptions: When Pre‑Operative Evaluation Is Indicated

Pre‑operative evaluation is warranted only if the patient has active cardiac conditions that require treatment before any surgery, regardless of surgical risk: 1

• Unstable coronary syndromes (unstable or severe angina, recent MI within 30 days). 1
• Decompensated heart failure (NYHA Class IV, worsening or new‑onset heart failure). 1
• Significant arrhythmias (high‑grade AV block, Mobitz II or third‑degree heart block, symptomatic ventricular arrhythmias, uncontrolled atrial fibrillation with heart rate >100 bpm at rest, symptomatic bradycardia, newly recognized ventricular tachycardia). 1
• Severe valvular disease (severe aortic stenosis with mean gradient >40 mm Hg or valve area <1.0 cm², symptomatic mitral stenosis). 1

If none of these active cardiac conditions are present, the patient should proceed directly to cataract surgery. 1

Specific Guidance for This Patient's Comorbidities

• Coronary artery disease (stable): No additional testing required for low‑risk surgery. 1, 2
• Heart failure (compensated): No additional testing required unless the patient has current or worsening symptoms. 1
• Hypertension: No delay required unless blood pressure is ≥180/110 mm Hg (stage 3 hypertension), in which case blood pressure should be controlled before elective surgery. 1
• Type 2 diabetes: No additional testing required for low‑risk surgery. 1
• COPD: No additional testing required unless the patient has new or unstable cardiopulmonary symptoms. 1
• Chronic kidney disease: Elevated creatinine (>2 mg/dL) is a cardiac risk factor for intermediate‑ or high‑risk surgeries, but no EKG is needed for cataract surgery regardless of creatinine level. 2
• Chronic warfarin therapy: Coordinate with the ophthalmologist regarding peri‑operative anticoagulation management, but this does not require formal cardiac clearance. 1

What the Anesthesia Team Will Do on the Day of Surgery

• Anesthesia staff will perform a focused screening on the day of surgery to identify any acute changes in the patient's condition. 3
• This day‑of‑surgery screening is sufficient for cataract surgery patients and eliminates the need for a separate pre‑operative medical history and physical within 30 days of surgery. 3

Common Pitfalls to Avoid

• Do not order routine EKGs for asymptomatic patients undergoing low‑risk surgery; this practice raises costs without improving clinical outcomes (Class III: Harmful). 1, 4
• Do not reflexively order EKGs based on lab abnormalities alone (e.g., elevated creatinine) without considering the surgical risk. 2
• Do not use the phrase "cleared for surgery"; instead, document that "the patient may proceed with the planned low‑risk surgery with continuation of guideline‑directed medical therapy." 1
• Do not delay surgery to obtain unnecessary consultations or testing in stable patients undergoing low‑risk procedures. 1, 2

Recommended Documentation

Document the following in the medical record:

• Surgical risk classification: Cataract surgery is a low‑risk procedure (<1% cardiac event rate). 1
• Absence of active cardiac conditions: No unstable angina, decompensated heart failure, significant arrhythmias, or severe valvular disease. 1
• Stable comorbidities: All chronic conditions are at baseline without acute decompensation. 2
• Continuation of chronic medications: All cardiovascular medications (including warfarin, with ophthalmology coordination) should be continued peri‑operatively. 1
• Proceed to surgery: The patient may proceed with cataract surgery without formal pre‑operative clearance. 1, 2