Preop Cardiac Exam

The goals of the preoperative evaluation are to discover or identify a disease/disorder that may affect perioperative care; verification or assessment of a known disease; formation of plans and alternatives for anesthetic care.

EKG may be indicated for patients with known cardiovascular disease or risk factors. Advanced age may not be an indication for preanesthetic EKG in the absence of risk factors. Cardiac evaluation (e.g. cardiac consultation and non-invasive or invasive assessments of cardiac structure and function) may be indicated in patients with cardiovascular risk factors. The anesthesiologist should consider the patient’s risk factors and planned surgery as well as the risks, costs, and benefits of the consultation and testing.

ADLs can provide a fairly accurate view of functional status and estimation of perioperative cardiac risk. Perioperative cardiac and long-term risks are increased in patients unable to perform 4 METs of work during daily activities.

• < 4 METs: slow ballroom dancing, golfing with a cart, walking at 2-3 mph
• > 4 METs: climbing a flight of stairs or walking up a hill, walking on level ground at 4 mph, and performing heavy work around the house

Preoperative ECG

• Is reasonable for patients with known CAD, arrhythmia, PAD, CVD, or significant structural heart disease, unless the surgery is low-risk
• May be considered for asymptomatic patients without known cardiovascular disease, unless the surgery is low-risk
• Is not useful or routinely recommended for asymptomatic patients undergoing low-risk surgery

The need for further cardiac evaluation is dependent upon presence of symptoms, type of surgery, and urgency of surgery.

• If the surgery is emergent, risk stratify clinically and proceed to surgery
• If surgery is urgent or elective, evaluate the patient for active ACS symptoms.
  • If the patient has active or recent ACS symptoms, refer them to cardiology for evaluation.
  • If the patient does not have active or recent symptoms, estimate perioperative risk of MACE using NSQIP or RCRI tools.
    • If risk of MACE is low, proceed with surgery
    • If risk of MACE is elevated, assess functional capacity and consider whether consultation or further testing would change perioperative management.

If functional capacity is poor, consider pharmacologic stress test only if the results could change patient’s management; otherwise proceed to surgery with medical optimization or proceed with alternative treatment if available (e.g. radiation therapy for cancer treatment instead of surgical management).