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

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)