Guidelines for Preoperative Cardiac and Pulmonary Testing
The best assurance of a good postoperative outcome is that the patient is in optimal condition prior to surgery, as determined by the patient’s internist or cardiologist. The purpose of preoperative evaluation is to assure that no further diagnostic testing or medical therapy is necessary to optimize the patient. Our goals are to identify patients who cannot increase cardiac output in response to metabolic demands after major surgery, or who are at risk for cardiac complications despite optimal medical management.
For questions not answered in these guidelines, please call the Preoperative Evaluation and Planning Clinic (PEPC) at 310-794-4494, or refer to the ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery.
Major risk factors for cardiac complications after non-cardiac surgery include:
- Prior MI
- History of CHF
- Peripheral arterial disease, including a history of stroke or TIA
- Chronic renal disease
- Abnormal EKG
High-risk and intermediate-risk operations include:
- Aortic surgery
- Lower extremity revascularization
- Thoracic surgery
- Kidney transplantation
- Major head-and-neck surgery
- Operations where major blood loss and/or fluid shifts may be anticipated (general surgery, gynecology, orthopedics, urology)
Indicated only for patients with known pathology, congestive heart failure, or recent pneumonia.
Men over the age of 50 and women over the age of 60 should have a 12-lead EKG if one has not been performed in the past year. A patient of any age with cardiopulmonary disease, renal disease, hypertension, or diabetes, should also have a preoperative EKG performed close to the date of the procedure. Please send a copy of the EKG, with interpretation, along with a prior EKG if available.
If the EKG is abnormal, or shows significant change from prior EKGs, the patient’s internist or cardiologist should determine the need for any additional assessment of cardiac functional status or coronary artery disease.
No further work-up is indicated for patients with good functional capacity, who can generate an activity level of greater than 7 METS or tolerate a heart rate of 130 or more without symptoms.
Non-invasive stress testing, including assessment of ventricular function, may be indicated for patients who:
- Experience angina or dyspnea on exertion
- Have risk factors for coronary artery disease
- Have risk factors for CHF exacerbation
- Have had no diagnostic stress testing within the past 2 years, or appear clinically worse than when previously tested.
Patients who have poor exercise tolerance, or for whom exercise tolerance cannot be assessed, should undergo non-invasive stress testing if:
- No stress test has been performed in the past 2 years
- The planned surgery is high-risk or intermediate-risk
- They have at least one risk factor for postoperative cardiac complications.
If a patient has had a previously abnormal stress test, and has poor exercise tolerance, cardiologist evaluation is indicated to optimize risk reduction.
In the presence of valvular heart disease or pulmonary hypertension, the patient’s internist or cardiologist should reassess the severity of disease and address any evidence of progression since the previous evaluation.
Patients with pacemakers should have an evaluation of settings and battery function within 6 months of the procedure.
A patient with an implanted defibrillator (ICD) or a cardiac resynchronization therapy (CRT) device should have the device checked within 3 months of the procedure.
Patients may be referred to the UCLA Kurlan Heart Center (310-794-1710) for evaluation of device function, and to arrange for reprogramming if needed immediately before surgery.
Patients who are scheduled for lung resection or other major thoracic surgery should have preoperative pulmonary function testing, but it is not indicated for most other procedures.
If a patient has received a sleep study, please send the results with the patient’s other records. Otherwise, a “STOP-BANG” questionnaire assessment of sleep apnea is sufficient.