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.
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:
- Ischemic Heart Disease (History of MI, positive stress test, or angina).
- Congestive Heart Failure (History of CHF, PND, or S3 gallop).
- Cerebrovascular Disease (History of TIA or Stroke).
- Diabetes Mellitus (Requiring insulin).
- Renal Insufficiency (Creatinine > 2.0 mg/dL).
- 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. |
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.
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. |