Preoperative Medical Assessment AND Optimisation

Meet the patient

Mrs Okafor, sixty-eight, is booked for a total hip replacement. She has hypertension, type 2 diabetes (HbA1c 8.0 percent), former heavy smoking now cut to five a day, and osteoarthritis so severe she "cannot climb a flight of stairs without stopping." She takes ramipril, metformin, gliclazide, and atorvastatin. The surgical team has asked you to "clear her for theatre." The question on every preoperative assessment is the same: what is her risk, what can I optimise, and what testing and medication changes will actually change her outcome?[1][3]

This is the station that rewards restraint and structure. The candidate who reaches for a stress test on every patient, or who starts a beta-blocker on the morning of surgery to "clear" them, fails. The 2024 AHA/ACC/ACS guideline, the ESC/ESA guideline, and the Canadian Cardiovascular Society guidance converge on one algorithm: assess clinical risk and surgery risk, test only if the result will change management, optimise what is modifiable, and continue the drugs that are working.[1][2][4]

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1. [1]Thompson A, Fleischmann KE, Smilowitz NR, et al. 2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM Guideline for Perioperative Cardiovascular Management for Noncardiac Surgery: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines Journal of the American College of Cardiology, 2024.PMID 39320289
2. [2]Duceppe E, Parlow J, MacDonald P et al. Canadian Cardiovascular Society Guidelines on Perioperative Cardiac Risk Assessment and Management for Patients Who Undergo Noncardiac Surgery The Canadian journal of cardiology, 2017.PMID 27865641
3. [3]Raslau D, Bierle DM, Stephenson CR et al. Preoperative Cardiac Risk Assessment Mayo Clinic proceedings, 2020.PMID 32107033
4. [4]Kristensen SD, Knuuti J, Saraste A et al. 2014 ESC/ESA Guidelines on non-cardiac surgery: cardiovascular assessment and management: The Joint Task Force on non-cardiac surgery: cardiovascular assessment and management of the European Society of Cardiology (ESC) and the European Society of Anaesthesiology (ESA) European heart journal, 2014.PMID 25086026
5. [5]Sameed M, Choi H, Auron M et al. Preoperative Pulmonary Risk Assessment Respiratory care, 2021.PMID 34210743
6. [6]Qaseem A, Snow V, Fitterman N et al. Risk assessment for and strategies to reduce perioperative pulmonary complications for patients undergoing noncardiothoracic surgery: a guideline from the American College of Physicians Annals of internal medicine, 2006.PMID 16618955
7. [7]Douketis JD, Spyropoulos AC Perioperative Management of Patients Taking Direct Oral Anticoagulants: A Review JAMA, 2024.PMID 39133476
8. [8]Douketis JD, Spyropoulos AC Perioperative Management of Anticoagulant and Antiplatelet Therapy NEJM evidence, 2023.PMID 38320132
9. [9]Smilowitz NR, Berger JS Perioperative Cardiovascular Risk Assessment and Management for Noncardiac Surgery: A Review JAMA, 2020.PMID 32692391
10. [10]Benesch C, Glance LG, Derdeyn CP et al. Perioperative Neurological Evaluation and Management to Lower the Risk of Acute Stroke in Patients Undergoing Noncardiac, Nonneurological Surgery: A Scientific Statement From the American Heart Association/American Stroke Association Circulation, 2021.PMID 33827230