Cardiology — Preoperative Cardiac Clearance Template

Consultation Information

Referring physician: [Name, specialty]
Reason for consultation: Preoperative cardiac evaluation
Date of evaluation: [Date]
Planned surgery: [Procedure name]
Planned surgery date: [Date]
Surgical facility: [Hospital/ASC name]
Anesthesia type: General / Regional / MAC / Local

Proposed Surgical Procedure

Procedure: [Detailed description]
Surgical risk category (ACC/AHA):

• Low risk (<1% MACE): Yes / No
• Elevated risk (≥1% MACE): Yes / No

Specific procedure risk factors: [Vascular, intrathoracic, intraperitoneal, orthopedic, etc.]
Estimated blood loss: Minimal / Moderate / Significant
Estimated duration: [X] hours
Emergency vs elective: Elective / Urgent / Emergency

Functional Capacity Assessment

Can patient climb 2 flights of stairs without stopping? Yes / No
Can patient walk 4 blocks on level ground? Yes / No
Can patient do heavy housework (scrubbing floors, lifting)? Yes / No
Estimated METs:

• ≥4 METs (adequate): Yes / No
• <4 METs (poor): Yes / No
• Unable to assess: Yes / No — Reason: [Orthopedic limitation, deconditioning, etc.]

DASI Score (if calculated): [X] — Estimated METs: [X]

Cardiac History

Coronary artery disease: None / [History: MI dates, PCI dates, CABG date]

• Last cardiac catheterization: [Date, findings]
• Stent type if PCI: BMS / DES — Date placed: [X]

Heart failure: None / HFrEF / HFpEF — EF: [X]%

• Compensated: Yes / No

Valvular disease: None / [Valve, severity]

• Moderate-severe AS: Yes / No (critical for risk)

Arrhythmias: None / AFib / Other [specify]

• Pacemaker/ICD: Yes / No — Type: [X]

Pulmonary hypertension: None / [Severity if known]
Congenital heart disease: None / [Details]

Active Cardiac Conditions (ACC/AHA)

Check all that apply:
[ ] Unstable coronary syndromes (unstable angina, recent MI)
[ ] Decompensated heart failure
[ ] Significant arrhythmias (high-grade AV block, symptomatic ventricular arrhythmias, SVT with uncontrolled rate, symptomatic bradycardia, new VT)
[ ] Severe valvular disease (severe AS, symptomatic MS)
Active cardiac conditions present: Yes / No
If YES: Surgery should be delayed for evaluation and treatment

Clinical Risk Factors (RCRI)

Revised Cardiac Risk Index:
[ ] High-risk surgery (1 point)
[ ] History of ischemic heart disease (1 point)
[ ] History of heart failure (1 point)
[ ] History of cerebrovascular disease (1 point)
[ ] Diabetes requiring insulin (1 point)
[ ] Creatinine >2.0 mg/dL (1 point)
RCRI Score: [0-6]
Estimated MACE risk: [<1% / 1-5% / 5-10% / >10%]

Cardiovascular Risk Factors

Hypertension: Yes / No — Controlled: Yes / No
Diabetes: Yes / No — Type [1/2], A1c: [X]%
Hyperlipidemia: Yes / No — On statin: Yes / No
Smoking: Current / Former / Never
Obesity: Yes / No — BMI: [X]
CKD: Yes / No — GFR: [X]
Age: [X] years

Current Cardiac Medications

Antiplatelet agents:

• Aspirin: [Dose] — Continue / Hold [X days]
• P2Y12 inhibitor: [Drug, dose] — Continue / Hold [X days]
• Indication: Recent stent (<12 months DES, <30 days BMS) / ACS / Other

Anticoagulants:

• [Agent, dose] — Continue / Hold / Bridge
• Indication: [AFib, mechanical valve, VTE]

Beta-blockers: [Drug, dose] — Continue perioperatively
ACEi/ARB: [Drug, dose] — Continue / Hold day of surgery
Diuretics: [Drug, dose] — Hold day of surgery / Continue
Statins: [Drug, dose] — Continue perioperatively
Other: [List]

Physical Examination

Vital signs: BP [X/X], HR [X], RR [X], SpO2 [X]%
General: [Appearance, distress level]
Cardiovascular:

• JVP: Normal / Elevated [X cm]
• Carotid: Normal / Bruit / Diminished
• Heart rhythm: Regular / Irregular
• Murmurs: None / [Grade, location, timing]
• AS murmur characteristics: [If applicable]
• S3/S4: Absent / Present
• Edema: None / [Grade, location]

Lungs: Clear / [Findings]
Peripheral pulses: [Assessment]

Diagnostic Studies

ECG: [Date, rhythm, rate, intervals, ischemic changes, conduction abnormalities]

• New findings: Yes / No

Echocardiogram: [Date if recent]

• EF: [X]%
• Wall motion: Normal / [Abnormalities]
• Valves: [Assessment, especially AS severity]
• RVSP: [X] mmHg

Stress test: [Date, type, result if recent]

• Ischemia: None / [Location, extent]
• Functional capacity: [METs achieved]

Labs: Cr [X], GFR [X], Hgb [X], BNP [X if obtained]

Risk Assessment Summary

Surgical risk: Low / Elevated
Functional capacity: ≥4 METs / <4 METs / Unable to assess
Active cardiac conditions: Present / Absent
RCRI Score: [X] — Estimated MACE: [X]%
Combined perioperative MACE risk: Low (<1%) / Intermediate (1-5%) / High (>5%)

Recommendations

Preoperative Testing

Additional testing needed: Yes / No

• [ ] Echocardiogram — Indication: [Dyspnea, murmur, HF symptoms]
• [ ] Stress testing — Indication: [Poor functional capacity + elevated surgical risk + will change management]
• [ ] Cardiac catheterization — Indication: [High-risk features on stress test]

Rationale: [Why testing is/is not indicated per ACC/AHA guidelines]

Perioperative Medication Management

1) Beta-blockers:

• Continue current beta-blocker perioperatively
• Do NOT initiate high-dose beta-blocker on day of surgery

2) Antiplatelet therapy:

• Aspirin: [Continue / Hold X days preop / Resume postop day X]
• P2Y12 inhibitor: [Continue / Hold X days preop / Resume postop day X]
• Dual antiplatelet delay: [If recent stent, minimum time to delay surgery]

3) Anticoagulation:

• [Agent]: [Continue / Hold X days / Bridge with LMWH]
• Resume: [Timing postoperatively]

4) ACEi/ARB: Hold morning of surgery, resume when hemodynamically stable
5) Statins: Continue perioperatively
6) Diuretics: [Hold / Continue] day of surgery

Device Management (if applicable)

Pacemaker/ICD present: Yes / No

• Interrogation needed preop: Yes / No
• Reprogramming needed: [Magnet mode, disable tachy therapy]
• Electrocautery precautions: [Recommendations]
• Postop interrogation: Yes / No

Surgical Clearance

Cardiac clearance for surgery: GRANTED / DEFERRED / NOT GRANTED
Conditions for clearance:

• [List any conditions that must be met]

Risk acknowledged: Patient is at [low/intermediate/high] cardiac risk for this procedure

Follow-up

Preoperative: [Any additional testing or visits needed]
Postoperative: [Cardiology follow-up timing]

• Telemetry recommended: Yes / No — Duration: [X] hours
• Troponin monitoring: Yes / No — Indication: [High-risk patient]

Communication

Discussed with:

• Patient: [Risks, recommendations, questions addressed]
• Surgeon: [Name, discussed risk and recommendations]
• Anesthesia: [If applicable]

Report sent to: [Surgeon, PCP, surgical facility]

Summary Statement

[Patient name] is a [age]-year-old [male/female] with [cardiac history summary] presenting for preoperative cardiac evaluation prior to [procedure]. Surgical risk is [low/elevated]. Functional capacity is [adequate/poor/unable to assess]. RCRI score is [X] with estimated MACE risk of [X]%. [No active cardiac conditions are present / Active cardiac conditions include X].
Based on ACC/AHA guidelines, [additional testing is/is not indicated]. The patient is [cleared / conditionally cleared / not cleared] for surgery with the above recommendations for perioperative medication management.