Cases and Questions

Evaluation of Cardiac Risk Before Noncardiac Surgery
AF is a 61 y/o male scheduled for cholecystectomy, for symptomatic gallstones. The
surgery is scheduled for 2 weeks from today. The patient has a history of hypertension for the
past 16 years. He states that his blood pressure is usually in the 140-150/80-90. One year ago he
was admitted to the hospital with chest pain and was diagnosed to have an acute MI. He had a
LAD drug eluting stent placed. He was discharged after four days. He denies any chest pain
since his MI. He denies dyspnea on exertion, PND, or orthopnea. He is able to walk 4 blocks.
He also has a history of hypercholesterolemia. He denies any history of excessive
bleeding. His medications are hydrochlorothiazide 25mg qAM, Lipitor 40 mg daily, one aspirin
daily, and Plavix. His prior surgery was 35 years ago when he underwent an emergency
laparotomy and splenectomy following trauma. Because of his prior laparotomy his present
surgeon told him that his cholecystectomy probably cannot be done laparoscopically. He denies
any known complications following that surgery. He smoked cigarettes, 3 packs per day for 37
years until quitting when he had his MI one year ago. He denies drinking alcohol.
On exam he is in no distress. His blood pressure is 140/90. You repeat his BP and it is
132/82. His pulse is 60 and regular. On HEENT exam, he is PERRLA and EOMI. His neck
reveals no JVD and no thyromegaly. His lungs are clear to auscultation and percussion, he has
decreased breath sounds bilaterally symmetrically. On cardiac exam S1 and S2 are normal.
There is no S3, S4, or murmurs. His abdomen is obese, soft, and nontender, he has a midline
scar. His extremities are without clubbing, cyanosis or edema. On neurologic exam cranial
nerves 2-12 are intact.
His hemoglobin is 16.4. His BMP is normal except for a glucose of 103. His EKG shows
NSR with a rate of 60, left axis deviation, and LVH.
1. What are his medical problems?
2. Which if any of these might have a significant effect on the risk of the planned surgical
procedure? Why?
3. What is the risk of this planned surgery?
4. Should anything be done preoperatively to modify that risk?
Is there anything you would recommend perioperatively for this patient?
RH is an 82 year old woman scheduled for L total knee replacement. She is referred to
your clinic for a preoperative medical evaluation because her blood pressure was elevated on her
preadmission screening exam. She states that she had not seen a doctor for 15-20 years until her
knee pain started interfering with her walking. She denies a past history of hypertension. She
denies a history of chest pain or MI. She is able to walk one block, and then has to stop because
of knee pain and fatigue. She denies SOB except when she goes up one flight of stairs. She has
slept on two pillows for the past 3 months because that is the only way she is comfortable. Her
only medication is advil prn for knee pain. She smoked cigarettes 1 ppd for 40 years until
quitting 8 years ago. She does not drink alcohol. She denies prior surgery.
On exam she is an elderly female in NAD. Her BP is 160/98 and her pulse is 88. Her
RR is 18. On HEENT she is PERRLA and EOMI. Her lungs are clear. Cardiac exam reveals a
normal S1 and S2. She has a 2/6 SEM at the apex. Her abdomen is soft and non-tender. Her
extremities have 2mm of pitting edema bilaterally.
Her EKG shows NSR, Q waves in 2, 3, and AVF, and nonspecific ST segment changes.
Her Hb is 13. Her CMP is WNL.
1. What are her medical problems?
2 Which if any of these might have a significant effect on the risk of the planned surgical
3. What is the risk of this planned surgery?
4. What would you recommend to be done at this point? Would you recommend any other
tests or treatment?