{"id":66278,"date":"2026-02-16T18:46:45","date_gmt":"2026-02-16T13:16:45","guid":{"rendered":"https:\/\/johnsonfrancis.org\/professional\/?p=66278"},"modified":"2026-02-16T18:46:49","modified_gmt":"2026-02-16T13:16:49","slug":"cardiac-clearance-checklist-the-high-yield-pre-op-workup-for-non-cardiac-surgery","status":"publish","type":"post","link":"https:\/\/johnsonfrancis.org\/professional\/cardiac-clearance-checklist-the-high-yield-pre-op-workup-for-non-cardiac-surgery\/","title":{"rendered":"Cardiac Clearance Checklist: The High-Yield Pre-Op Workup for Non-Cardiac Surgery"},"content":{"rendered":"<iframe loading=\"lazy\" width=\"560\" height=\"315\" src=\"https:\/\/www.youtube.com\/embed\/SwzjAgDXpMA?si=1mGgwtwKLIqDG5hj\" title=\"YouTube video player\" frameborder=\"0\" allow=\"accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture; web-share\" referrerpolicy=\"strict-origin-when-cross-origin\" allowfullscreen><\/iframe>\n\n<p class=\"wp-block-paragraph\">A cardiac &#8220;clearance&#8221; is less about giving a &#8220;green light&#8221; and more about <strong>risk stratification<\/strong> and <strong>optimization<\/strong>. Here is a roadmap for evaluating patients before they head to the operating room in a simplified and easy to remember form.<\/p>\n\n\n\n<hr class=\"wp-block-separator has-alpha-channel-opacity\"\/>\n\n\n\n<h2 class=\"wp-block-heading\">Step One: The &#8220;Urgency&#8221; Filter<\/h2>\n\n\n\n<p class=\"wp-block-paragraph\">Before diving into tests, determine if the surgery is even a candidate for a workup.<\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li class=\"\"><strong>Is it an Emergency?<\/strong> If life or limb is at stake, the patient goes to the OR. Your job shifts to post-op management and intra-op monitoring.<\/li>\n\n\n\n<li class=\"\"><strong>Is it Low Risk?<\/strong> Procedures like cataracts, plastic surgery, or superficial biopsies have a &lt; 1% risk of Major Adverse Cardiac Events (MACE). No further testing is usually required.<\/li>\n<\/ul>\n\n\n\n<h2 class=\"wp-block-heading\">Step Two: Clinical Risk Factors<\/h2>\n\n\n\n<p class=\"wp-block-paragraph\">Identify the &#8220;Red Flags.&#8221; Use the <strong><a href=\"https:\/\/pubmed.ncbi.nlm.nih.gov\/10477528\/\" type=\"link\" id=\"https:\/\/pubmed.ncbi.nlm.nih.gov\/10477528\/\">Revised Cardiac Risk Index (RCRI)<\/a><\/strong>. One point for each:<\/p>\n\n\n\n<ol start=\"1\" class=\"wp-block-list\">\n<li class=\"\"><strong>Ischemic Heart Disease<\/strong> (History of MI, positive stress test, or angina).<\/li>\n\n\n\n<li class=\"\"><strong>Congestive Heart Failure<\/strong> (History of CHF, PND, or S3 gallop).<\/li>\n\n\n\n<li class=\"\"><strong>Cerebrovascular Disease<\/strong> (History of TIA or Stroke).<\/li>\n\n\n\n<li class=\"\"><strong>Diabetes Mellitus<\/strong> (Requiring insulin).<\/li>\n\n\n\n<li class=\"\"><strong>Renal Insufficiency<\/strong> (Creatinine > 2.0 mg\/dL).<\/li>\n\n\n\n<li class=\"\"><strong>High-Risk Surgery<\/strong> (Intraperitoneal, intrathoracic, or suprainguinal vascular).<\/li>\n<\/ol>\n\n\n\n<blockquote class=\"wp-block-quote is-layout-flow wp-block-quote-is-layout-flow\">\n<p class=\"wp-block-paragraph\"><strong>The Scorecard:<\/strong><\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li class=\"\"><strong>0\u20131 Points:<\/strong> Low Risk.<\/li>\n\n\n\n<li class=\"\"><strong>\u2265 2 Points:<\/strong> Elevated Risk\u2014Proceed to functional capacity assessment.<\/li>\n<\/ul>\n<\/blockquote>\n\n\n\n<h2 class=\"wp-block-heading\">Step Three: Functional Capacity (METs)<\/h2>\n\n\n\n<p class=\"wp-block-paragraph\">Can the patient\u2019s heart handle a &#8220;stress test&#8221; in real life? We measure this in <strong>Metabolic Equivalents (METs)<\/strong>.<\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li class=\"\"><strong>Can they climb two flights of stairs or walk up a hill without stopping?<\/strong> (> 4 METs)<\/li>\n\n\n\n<li class=\"\"><strong>If METs \u2265 4:<\/strong> Proceed to surgery.<\/li>\n\n\n\n<li class=\"\"><strong>If METs &lt; 4 (or unknown):<\/strong> This is where you consider further testing (Stress Test) if it will change management.<\/li>\n<\/ul>\n\n\n\n<h2 class=\"wp-block-heading\">Step Four: High-Yield Testing Guidelines<\/h2>\n\n\n\n<p class=\"wp-block-paragraph\">Here are a few suggestions for investigations<\/p>\n\n\n\n<figure class=\"wp-block-table\"><table class=\"has-fixed-layout\"><thead><tr><td><strong>Test<\/strong><\/td><td><strong>Indication<\/strong><\/td><\/tr><\/thead><tbody><tr><td><strong>ECG<\/strong><\/td><td>Baseline for patients with known CAD, arrhythmia, or structural heart disease (unless it\u2019s low-risk surgery).<\/td><\/tr><tr><td><strong>Echo<\/strong><\/td><td>If there is <strong>new or worsening<\/strong> dyspnea, or a clinical suspicion of moderate-to-severe valvular disease (e.g., a new Grade III systolic murmur).<\/td><\/tr><tr><td><strong>Stress Test<\/strong><\/td><td>For patients with <strong>elevated risk<\/strong> AND <strong>poor\/unknown functional capacity<\/strong>, especially if the results will change the plan (e.g., lead to revascularization).<\/td><\/tr><tr><td><strong>BNP<\/strong><\/td><td>Emerging as a strong predictor of perioperative MACE, but not yet a &#8220;must-have&#8221; for every patient.<\/td><\/tr><\/tbody><\/table><\/figure>\n\n\n\n<hr class=\"wp-block-separator has-alpha-channel-opacity\"\/>\n\n\n\n<h2 class=\"wp-block-heading\">The &#8220;Golden Rules&#8221; of Optimization<\/h2>\n\n\n\n<ul class=\"wp-block-list\">\n<li class=\"\"><strong>Beta-Blockers:<\/strong> Do <strong>not<\/strong> start them the morning of surgery (<a href=\"https:\/\/pubmed.ncbi.nlm.nih.gov\/18479744\/\" type=\"link\" id=\"https:\/\/pubmed.ncbi.nlm.nih.gov\/18479744\/\">increases stroke risk<\/a>). If they are already on them, continue them.<\/li>\n\n\n\n<li class=\"\"><strong>Statins:<\/strong> Continue them. If they are undergoing vascular surgery, starting them early is beneficial.<\/li>\n\n\n\n<li class=\"\"><strong>ACEi\/ARBs:<\/strong> Generally held 24 hours prior to surgery to avoid intraoperative hypotension.<\/li>\n\n\n\n<li class=\"\"><strong>Dual Antiplatelet Therapy (DAPT):<\/strong> This is the tricky one. Consult Cardiology if a stent was placed within the last 6\u201312 months.<\/li>\n<\/ul>\n\n\n\n<hr class=\"wp-block-separator has-alpha-channel-opacity\"\/>\n\n\n\n<h3 class=\"wp-block-heading\">Summary Table for Decision Making<\/h3>\n\n\n\n<figure class=\"wp-block-table\"><table class=\"has-fixed-layout\"><thead><tr><td><strong>Patient Profile<\/strong><\/td><td><strong>Action<\/strong><\/td><\/tr><\/thead><tbody><tr><td><strong>Low-risk surgery<\/strong><\/td><td>Proceed to OR.<\/td><\/tr><tr><td><strong>Elevated risk + METs &gt; 4<\/strong><\/td><td>Proceed to OR (optimize meds).<\/td><\/tr><tr><td><strong>Elevated risk + METs &lt; 4<\/strong><\/td><td>Consider Stress Test \/ Cardiology Consult.<\/td><\/tr><tr><td><strong>Unstable Angina \/ Decompensated CHF<\/strong><\/td><td>Cancel elective surgery; treat first.<\/td><\/tr><\/tbody><\/table><\/figure>\n\n\n\n<hr class=\"wp-block-separator has-alpha-channel-opacity\"\/>\n","protected":false},"excerpt":{"rendered":"<p>A cardiac &#8220;clearance&#8221; is less about giving a &#8220;green light&#8221; 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 &#8220;Urgency&#8221; Filter Before diving into tests, determine if the surgery is even a [&hellip;]<\/p>\n","protected":false},"author":1,"featured_media":66284,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"nf_dc_page":"","footnotes":""},"categories":[9],"tags":[],"class_list":["post-66278","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-general"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v27.9 - https:\/\/yoast.com\/product\/yoast-seo-wordpress\/ -->\n<title>Cardiac Clearance Checklist: The High-Yield Pre-Op Workup for Non-Cardiac Surgery - All About Cardiovascular System and Disorders<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/johnsonfrancis.org\/professional\/cardiac-clearance-checklist-the-high-yield-pre-op-workup-for-non-cardiac-surgery\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Cardiac Clearance Checklist: The High-Yield Pre-Op Workup for Non-Cardiac Surgery - All About Cardiovascular System and Disorders\" \/>\n<meta property=\"og:description\" content=\"A cardiac &#8220;clearance&#8221; is less about giving a &#8220;green light&#8221; 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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