Cardiac Clearance Checklist: The High-Yield Pre-Op Workup for Non-Cardiac Surgery

A cardiac “clearance” is less about giving a “green light” and more about risk stratification and optimization. Here is a roadmap for evaluating patients before they head to the operating room in a simplified and easy to remember form.

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Step One: The “Urgency” Filter

Before diving into tests, determine if the surgery is even a candidate for a workup.

• Is it an Emergency? If life or limb is at stake, the patient goes to the OR. Your job shifts to post-op management and intra-op monitoring.
• Is it Low Risk? Procedures like cataracts, plastic surgery, or superficial biopsies have a < 1% risk of Major Adverse Cardiac Events (MACE). No further testing is usually required.

Step Two: Clinical Risk Factors

Identify the “Red Flags.” Use the Revised Cardiac Risk Index (RCRI). One point for each:

1. Ischemic Heart Disease (History of MI, positive stress test, or angina).
2. Congestive Heart Failure (History of CHF, PND, or S3 gallop).
3. Cerebrovascular Disease (History of TIA or Stroke).
4. Diabetes Mellitus (Requiring insulin).
5. Renal Insufficiency (Creatinine > 2.0 mg/dL).
6. High-Risk Surgery (Intraperitoneal, intrathoracic, or suprainguinal vascular).

The Scorecard:

• 0–1 Points: Low Risk.
• ≥ 2 Points: Elevated Risk—Proceed to functional capacity assessment.

Step Three: Functional Capacity (METs)

Can the patient’s heart handle a “stress test” in real life? We measure this in Metabolic Equivalents (METs).

• Can they climb two flights of stairs or walk up a hill without stopping? (> 4 METs)
• If METs ≥ 4: Proceed to surgery.
• If METs < 4 (or unknown): This is where you consider further testing (Stress Test) if it will change management.

Step Four: High-Yield Testing Guidelines

Here are a few suggestions for investigations

Test	Indication
ECG	Baseline for patients with known CAD, arrhythmia, or structural heart disease (unless it’s low-risk surgery).
Echo	If there is new or worsening dyspnea, or a clinical suspicion of moderate-to-severe valvular disease (e.g., a new Grade III systolic murmur).
Stress Test	For patients with elevated risk AND poor/unknown functional capacity, especially if the results will change the plan (e.g., lead to revascularization).
BNP	Emerging as a strong predictor of perioperative MACE, but not yet a “must-have” for every patient.

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The “Golden Rules” of Optimization

• Beta-Blockers: Do not start them the morning of surgery (increases stroke risk). If they are already on them, continue them.
• Statins: Continue them. If they are undergoing vascular surgery, starting them early is beneficial.
• ACEi/ARBs: Generally held 24 hours prior to surgery to avoid intraoperative hypotension.
• Dual Antiplatelet Therapy (DAPT): This is the tricky one. Consult Cardiology if a stent was placed within the last 6–12 months.

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Summary Table for Decision Making

Patient Profile	Action
Low-risk surgery	Proceed to OR.
Elevated risk + METs > 4	Proceed to OR (optimize meds).
Elevated risk + METs < 4	Consider Stress Test / Cardiology Consult.
Unstable Angina / Decompensated CHF	Cancel elective surgery; treat first.

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