What pre‑operative cardiac fitness program (medical optimisation, functional assessment, and targeted exercise) should be provided for an adult patient with coronary artery disease, heart failure, valve disease or arrhythmia, who also has diabetes, hypertension, COPD, renal impairment, is taking a beta‑blocker, a statin, aspirin and an ACE‑inhibitor, and whose functional capacity is assessed in metabolic equivalents?

Preoperative Cardiac Fitness Assessment for Surgery

For a cardiac patient with multiple comorbidities, proceed directly to surgery without further cardiac testing if functional capacity is ≥4 METs (can climb 2 flights of stairs or walk 4 blocks without stopping); if functional capacity is <4 METs or unknown, obtain pharmacological stress testing only if results will change management decisions. 1

Step-by-Step Algorithm for Surgical Clearance

Step 1: Identify Active Cardiac Conditions (Immediate Evaluation Required)

Proceed with surgery only after addressing these conditions if present: 1

• Unstable coronary syndromes – unstable angina, recent MI within 30 days 1
• Decompensated heart failure – NYHA Class IV or worsening symptoms 1
• Significant arrhythmias – high-grade AV block, symptomatic ventricular arrhythmias, uncontrolled atrial fibrillation (resting rate >100 bpm) 1
• Severe valvular disease – severe aortic stenosis (mean gradient >40 mmHg or valve area <1.0 cm²), symptomatic mitral stenosis 1

If none of these conditions exist, proceed to Step 2.

Step 2: Assess Functional Capacity Using METs

This is the single most critical determinant of perioperative risk. 1

Ask two screening questions: 1, 2

• Can you climb 2 flights of stairs without stopping?
• Can you walk 4 blocks on level ground without stopping?

If YES to both → Functional capacity ≥4 METs → Proceed directly to surgery with guideline-directed medical therapy (GDMT) 1, 2

If NO to either → Functional capacity <4 METs → Proceed to Step 3 1, 2

Alternative: Use Duke Activity Status Index (DASI) 2

• DASI score >34 = adequate functional capacity (≥4 METs) → proceed to surgery 2
• DASI score ≤34 = poor functional capacity → proceed to Step 3 2

Step 3: Determine Surgical Risk Category

Low-risk surgery (<1% cardiac event rate): cataract, endoscopy, superficial procedures 1, 3

• Proceed directly to surgery regardless of functional capacity or risk factors 3
• No preoperative ECG, stress testing, or echocardiography needed 3

Intermediate-risk surgery (1-5% cardiac event rate): orthopedic, intra-abdominal, head/neck 1

High-risk surgery (>5% cardiac event rate): vascular, major thoracic, emergency procedures 1

Step 4: Decision for Further Testing (Intermediate/High-Risk Surgery Only)

For patients with poor (<4 METs) or unknown functional capacity undergoing intermediate or high-risk surgery: 1

Consult with patient and surgical team to determine if testing will impact decision-making: 1

• Will results change the decision to perform the original surgery?
• Is the patient willing to undergo coronary revascularization if significant disease is found?
• Will results alter perioperative management?

If YES → Obtain pharmacological stress testing (dobutamine stress echo or myocardial perfusion imaging) 1

• If abnormal: consider coronary angiography and revascularization based on extent of abnormality 1
• If normal: proceed to surgery with GDMT 1

If NO → Proceed directly to surgery with GDMT or consider alternative strategies (radiation therapy for cancer, palliation) 1

Preoperative Testing Recommendations

Electrocardiogram (ECG)

• Obtain ECG for patients with known coronary disease, structural heart disease, or significant comorbidities (diabetes, renal impairment) undergoing intermediate or high-risk surgery 1, 4
• Do NOT obtain ECG for asymptomatic patients undergoing low-risk surgery 1, 3

Left Ventricular Function Assessment

• Obtain echocardiography for patients with dyspnea of unknown origin or worsening heart failure symptoms 1
• Do NOT routinely assess LV function in clinically stable patients 1

Laboratory Testing (Based on Comorbidities)

• Complete blood count: for patients with chronic kidney disease, liver disease, or anticipated blood loss 4
• Electrolytes and creatinine: for patients on diuretics, ACE inhibitors, ARBs, or with hypertension, heart failure, diabetes, renal impairment 4
• Glucose/HbA1c: for diabetic patients if results will change perioperative management 4
• Coagulation studies: only if personal/family history of bleeding disorders or on anticoagulants 4

Biomarkers (Selective Use Only)

• Consider BNP/NT-proBNP for high-risk patients undergoing major surgery for prognostic information 4
• Consider troponin before and 48-72 hours after major surgery in high-risk patients 4
• Do NOT routinely measure biomarkers in all surgical patients 4

Medical Optimization (GDMT)

Continue These Medications Perioperatively

• Beta-blockers: continue in patients already taking them; do NOT start de novo immediately before surgery 1
• Statins: continue perioperatively 1
• ACE inhibitors: generally continue, though may hold morning of surgery based on institutional protocol 1
• Aspirin: continue for patients with coronary stents or recent acute coronary syndrome unless bleeding risk is prohibitive 1

Optimize Comorbidities Before Elective Surgery

• Hypertension: defer elective surgery if BP ≥180/110 mmHg 3
• Diabetes: optimize glycemic control (target HbA1c <8% for elective surgery) 4
• COPD: ensure bronchodilator therapy is optimized; consider preoperative pulmonary function testing for lung resection 1
• Renal impairment: check electrolytes, avoid nephrotoxins, ensure adequate hydration 4

Common Pitfalls to Avoid

Do NOT delay surgery for unnecessary testing in stable patients with good functional capacity – management is rarely changed by additional testing in patients who can achieve ≥4 METs 1, 2

Do NOT order routine stress testing for low-risk surgery – this is Class III (No Benefit) regardless of cardiac history 1

Do NOT use age alone as an indication for testing – functional capacity and comorbidities are more predictive than chronological age 4

Do NOT obtain coronary angiography routinely – this is Class III (No Benefit) 1

Do NOT start beta-blockers immediately before surgery – this increases perioperative stroke and mortality risk 1

Avoid the phrase "cleared for surgery" – instead document "patient may proceed with planned surgery with continuation of GDMT" 3

Special Consideration: Preoperative Exercise Rehabilitation

For patients with poor functional capacity undergoing elective high-risk surgery, consider preoperative exercise training (prehabilitation) – this may decrease length of stay, reduce postoperative complications, and improve physical functioning 5, 6

• Structured aerobic and resistance training programs for 2-6 weeks preoperatively have shown benefit in cardiac and vascular surgery patients 5
• This is particularly relevant for patients with coronary disease, heart failure, or valve disease who have time before elective procedures 7, 6