Cardiac Clearance for Orthopedic Surgeries in Patients with Cardiac Disease

Initial Assessment

The American College of Cardiology recommends a comprehensive cardiac evaluation to identify serious cardiac conditions, including unstable coronary syndromes, prior angina, recent myocardial infarction, decompensated heart failure, significant arrhythmias, and severe valvular disease, in patients with cardiac disease undergoing orthopedic surgery 1, 2
The American Heart Association suggests documenting history of pacemakers, implantable cardioverter defibrillators, and orthostatic intolerance in patients with cardiac disease 2, 3
The American College of Cardiology advises recording any recent changes in cardiac symptoms in patients with established cardiac disease 1
The American Heart Association recommends documenting all current medications, including dosages, as well as use of herbal supplements, alcohol, tobacco, and illicit drugs, in patients with cardiac disease 1

The American College of Cardiology defines unstable coronary syndromes as unstable or severe angina, recent myocardial infarction within 30 days, which requires evaluation and treatment before surgery 3
The American Heart Association defines decompensated heart failure as NYHA functional class IV, worsening or new-onset heart failure, which requires evaluation and treatment before surgery 3
The American College of Cardiology identifies significant arrhythmias, including high-grade AV block, Mobitz II AV block, third-degree heart block, symptomatic ventricular arrhythmias, and supraventricular arrhythmias with uncontrolled ventricular rate, which require evaluation and treatment before surgery 3
The American Heart Association defines severe valvular disease as severe aortic stenosis, symptomatic mitral stenosis, which requires evaluation and treatment before surgery 3

The American College of Cardiology recommends evaluating the patient's ability to perform daily activities, as this correlates with maximum oxygen uptake, to assess functional capacity 3, 4
The American Heart Association suggests that patients who can perform activities requiring ≥4 METs generally have lower perioperative risk 4
The American College of Cardiology advises that a patient with known cardiac disease who is asymptomatic and exercises regularly may need less extensive evaluation than a sedentary patient 2

The American Heart Association recommends including vital signs, carotid pulse contour and bruits, jugular venous pressure and pulsations, lung auscultation, precordial palpation and auscultation, abdominal examination, and extremity examination for edema and vascular integrity in the physical examination 4

The American College of Cardiology advises that preoperative tests should only be ordered if results will change surgical procedure, medical therapy, monitoring during/after surgery, or lead to postponement until cardiac condition is stabilized 1
The American Heart Association suggests avoiding redundant testing and only ordering tests that have the potential to affect treatment 1
The American College of Cardiology notes that anemia is associated with increased perioperative ischemia and complications in vascular surgery patients 4

The American College of Cardiology recommends avoiding the use of phrases like "clear for surgery" in consultation notes and ensuring clear communication between the consultant, surgeon, anesthesiologist, and other physicians 1, 2, 5
The American Heart Association suggests that the perioperative evaluation may be an opportunity to implement long-term cardiac risk reduction strategies 5
The American College of Cardiology advises documenting findings clearly in the medical record 1

The American College of Cardiology warns against ordering tests that will not change management decisions 1
The American Heart Association cautions against focusing only on short-term perioperative risk without addressing long-term cardiac risk management 5