Preoperative cardiac clearance checklist

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Prince Tano Djan, BSc, MBChB [2]; Tarek Nafee, M.D. [3]

Click to download a printable PDF of the checklist: File:Cardiac clearance checklist.pdf.

## Cardiac clearance form [1]

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A. Cardiac Risk By Type of Surgery (check the appropriate box)

High Risk (>5%)  | ❑ Emergent major operations, particularly elderly
❑ Aortic or major vascular
❑ Peripheral vascular surgery
❑ Upper abdominal
Intermediate Risk (1- 5% risk):  | ❑ Intraperitoneal
❑ Intrathoracic
❑ Carotid endarterectomy
❑ Head and neck surgery
❑ Gynecologic surgery
❑ Neurosurgery
❑ Orthopedic surgery
❑ Urologic surgery
Low Risk (<1%)  | ❑ Endoscopic procedures
❑ Superficial procedures
❑ Cataract surgery
❑ Breast surgery
❑ Ambulatory surgery
B. Contraindications for Non-Emergent Surgery (check the appropriate boxes)
❑ Acute Coronary Syndrome
❑ MI within 1 month
❑ Decompensated CHF
❑ Significant high grade AV block, SVT, Symptomatic Bradycardia
❑ Severe valvular disease (AVA<1cm², gradient >40mmHg, symptomatic MS)
❑ None of the Above
C. Revised Cardiac Risk Index (RCRI) - check all that apply
Condition  | Points
❑ Heart failure  | 1
❑ Cerebrovascular disease  | 1
❑ Ischemic heart disease  | 1
❑ Diabetes requiring insulin  | 1
❑ Creatinine >2.0mg/dL  | 1
❑ Undergoing any of the following:

* Suprainguinal vascular surgery
* Intraperitoneal surgery
* Intrathoracic surgery

| 1
Total RCRI Score  | _______________(sum of points above)
Interpretation of RCRI Score:
Score  | Risk of Cardiac Complications
❑ 0  | 0.4%
❑ 1  | 0.9%
❑ 2  | 7%
❑ ≥3  | ≥11%
D. Patient Medications
Relevant Medications  | Recommendations
Is the patient on Beta-Blocker? |
❑ Yes  | Continue medication (Class I)
❑ No  | Do not start therapy on day of surgery (Class III)
Is the patient on Statins? |
❑ Yes  | Continue medication (Class I)
❑ No  |
Is the patient on alpha-2 agonist? |
❑ Yes  |
❑ No  | No benefit for prevention of cardiac events (Class III)
Is the patient on anti-platelet therapy? |
❑ Yes  | Does the patient have a coronary stent?
❑ Yes  | During the first 4 to 6 weeks after coronary stent implantation,

dual antiplatelet therapy should be continued unless the relative

risk of bleeding outweighs the benefit of the prevention of stent

thrombosis.

(Class I)

If surgical procedure mandates the d/c of P2Y12 inhibitor therapy,

it is recommended that aspirin be continued if possible and the

P2Y12 inhibitor be restarted as soon as possible after surgery.

(Class I)

Management of the perioperative antiplatelet therapy should be

determined by a consensus of the surgeon, anesthesiologist,

cardiologist, and patient, who should weigh the relative risk

of bleeding with that of stent thrombosis.

(Class I)

❑ No  | Continuation of aspirin is not beneficial in patients

undergoing elective noncardiac noncarotid surgery who have not

had previous coronary stent unless the risk of ischemic events

outweighs the risk of surgical bleeding.

(Class III)

❑ No  | Initiation of aspirin is not beneficial in patients

undergoing elective noncardiac noncarotid surgery who have not

had previous coronary stent unless the risk of ischemic events

outweighs the risk of surgical bleeding.

(Class III)

1. ↑ Halub ME, Sidwell RA (2015). "Cardiac risk stratification and protection". Surg Clin North Am. 95 (2): 217–35. doi:10.1016/j.suc.2014.11.007. PMID 25814103.