A 76-year-old woman comes to the office for preoperative evaluation. She has had worsening pain in her left knee with occasional swelling over the past several months. Her daughter has had to assist with household chores because the patient has difficulty using the stairs due to pain. Two weeks earlier she was seen by an orthopedic surgeon who recommended knee replacement surgery. The patient has no chest pain, although she admits she is not very active due to the knee pain. She also has no palpitations or shortness of breath while lying flat. Her other medical problems include obesity, hypertension, type 2 diabetes mellitus, obstructive sleep apnea, and history of peptic ulcer disease. Current medications include metformin, atorvastatin, and lisinopril. The patient monitors her blood glucose at home, with values around 110 mg/dL. She had a femoral hernia surgery 12 years ago without complications.
Blood pressure is 132/76 mm Hg and pulse is 72/min. BMI is 33.1 kg/m². Examination shows normal jugular venous distension and no carotid bruits. Heart sounds are normal and the lungs are clear to auscultation.
Hemoglobin is 12.2 g/dL, creatinine is 0.7 mg/dL, and potassium is 4.3 mEq/L. ECG shows normal sinus rhythm with T-wave inversion in lead III.
Which of the following is the most appropriate next step before surgery?

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Quizplus · Accepted Answer

11ec193a_974b_13a9_853d_39110973fb9d_MD0002_00 Managing perioperative cardiac risk prior to noncardiac surgery requires consideration of the type of surgery planned as well as patient clinical risk factors and functional status. In the absence of an active high-risk cardiac condition, patients undergoing low-risk surgery can proceed with surgery without further evaluation. Those undergoing intermediate- or high-risk surgery should have cardiovascular risk stratification using a validated prediction model such as the Revised Cardiac Risk Index (RCRI). Patients at low perioperative cardiac risk (≤1%) can undergo surgery without further evaluation, whereas those at moderate or high risk (>1%) should undergo an assessment of functional status to determine the need for further evaluation prior to surgery. Although risk estimates vary, the American Board of Internal Medicine calculator uses these estimates for RCRI. high-risk cardiac condition low-risk surgery validated prediction model functional status This patient's planned knee replacement is an intermediate-risk surgery. Based on the RCRI, she has no clinical risk factors for a major cardiac complication, which indicates low perioperative cardiac risk (estimated 0.4% risk). Such patients can proceed with surgery without further cardiac evaluation. T-wave inversions and/or ST depressions in the absence of history of coronary artery disease or symptoms are considered nonspecific and do not require further evaluation. Current guidelines recommend starting lipid-lowering therapy with statins as early as possible prior to surgery in appropriate patients to improve cardiovascular outcomes. Preoperative hemoglobin A1c levels provide an assessment of long-term glycemic control in patients with diabetes mellitus and can be helpful for titration of drug therapy prior to surgery. (Choice A) This patient has no history of bruising or bleeding diathesis and does not need a routine coagulation profile prior to surgery. (Choices B and C) Preoperative stress testing is recommended in patients who are at moderate or high cardiac risk (>1%) based on the RCRI and have poor functional status (unable to perform ≥4 METS of activity), if the results of such testing will change management. (Choice E) Transthoracic echocardiogram is appropriate prior to noncardiac surgery in patients with decompensated heart failure or suspected significant valvular disease (eg, severe aortic stenosis, mitral stenosis); it can be considered in select patients with moderate or high cardiac risk and poor functional status. Educational objective: Noninvasive cardiac evaluation (eg, stress testing, echocardiography) is not indicated in most asymptomatic patients undergoing noncardiac surgery. It is reserved mainly for patients undergoing intermediate- or high-risk noncardiac surgery who have >1% estimated perioperative cardiac risk and poor functional capacity (<4 METS). __________ References: Bisoprolol and fluvastatin for the reduction of perioperative cardiac mortality and myocardial infarction in intermediate-risk patients undergoing noncardiovascular surgery: a randomized controlled trial (DECREASE-IV). (http://www.ncbi.nlm.nih.gov/pubmed/19474688) 2009 ACCF/AHA focused update on perioperative beta blockade incorporated into the ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery: a report of the American College of Cardiology Foundation/American Heart Association task force on practice guidelines. (http://www.ncbi.nlm.nih.gov/pubmed/19884473)

A 76-Year-Old Woman Comes to the Office for Preoperative Evaluation