When preop clearance is useful
Not every surgery needs cardiology involvement. The cases that benefit from clearance:
- Intermediate or high-risk procedures in patients over 50 or with cardiac risk factors — most abdominal, thoracic, orthopedic, or vascular surgeries fall in this bucket.
- Known cardiac disease — prior MI, coronary artery disease, heart failure, atrial fibrillation, valve disease, prior bypass or stents, implantable devices.
- Cardiac risk factors plus poor functional capacity — patients who cannot climb a flight of stairs without breathlessness, regardless of why.
- Asked for by the surgeon, anesthesiologist, or PCP — some surgical practices request it routinely for patients over a certain age or with multiple comorbidities.
The Revised Cardiac Risk Index (RCRI)
The most commonly used risk-estimation tool. Six factors, one point each:
- High-risk surgical procedure
- History of ischemic heart disease
- History of congestive heart failure
- History of cerebrovascular disease (stroke or TIA)
- Diabetes requiring insulin
- Preoperative creatinine > 2.0 mg/dL
Risk of major cardiac complication: 0 factors ≈ 0.4%; 1 factor ≈ 1%; 2 factors ≈ 2-7%; 3+ factors ≈ 5-11%. The RCRI plus functional capacity gives a useful framework for whether more testing changes management.
Functional capacity — the most important question
A patient who can comfortably achieve 4 METs of activity has, by that fact alone, an exercise-tolerance signal stronger than most stress-test results. The 4-MET threshold corresponds to:
- Climbing one flight of stairs without stopping
- Walking up a moderate hill
- Heavy housework (vacuuming, mopping)
- Walking on level ground at 4 mph
- Sex without limitation
- Light yard work
Patients who reliably do these things without cardiac symptoms usually do not need additional preop cardiac testing — the functional capacity itself is the answer. The patients who benefit from additional workup are those who cannot reach 4 METs OR whose functional capacity cannot be reliably assessed (sedentary, physically limited for other reasons, recent deconditioning).
When additional testing is added
The standard tests, when indicated:
- Stress test — exercise or pharmacologic, with or without imaging. Looks for inducible ischemia.
- Echocardiogram — when valvular disease or reduced ejection fraction is suspected or known.
- BNP or NT-proBNP — sometimes added in heart-failure patients for risk stratification.
- Coronary CT angiography or invasive angiography — rarely needed before non-cardiac surgery; reserved for specific patterns.
The principle is that testing is only worth doing if it would change peri-operative management — if the result would not change the plan, the test is not adding value.
Peri-operative medication management
The clearance letter typically addresses:
- Beta blockers — generally continue chronic beta blockers through surgery; do not start a beta blocker acutely for prevention.
- Antihypertensives — generally continue most through the morning of surgery, with some exceptions (some ACE inhibitors/ARBs are held the morning of major surgery to reduce hypotension risk).
- Statins — continue through surgery.
- Anticoagulants — usually require a structured bridging plan; the cardiology clearance often includes specific instructions.
- Antiplatelet therapy in stent patients — timing and continuation depend on stent age and procedure type.
- Diabetes medications — addressed in coordination with the patient's endocrinologist or PCP.
How virtual preop clearance works
- Records sent in advance. Surgical plan, prior cardiology notes, recent ECG, any echoes or stress tests, current medication list, list of all cardiac history.
- Visit by video — usually 20-30 minutes. History review, symptom assessment, functional capacity assessment, risk estimation, decision about additional testing.
- Additional testing if needed. Ordered to facilities near you; results return for cardiologist review.
- Clearance letter to surgeon and anesthesia. Sent electronically. Includes risk estimate, peri-operative medication plan, and any specific recommendations.
Why the virtual model fits
- Speed. Most patients can be evaluated and cleared within a week of booking; sometimes same week of surgery.
- Records-driven. Most of the work is history and records review — fully workable by video.
- Coordination. The clearance letter transmits electronically to the surgical team; no in-person handoff needed.
- No physical-exam barrier. The exam adds little to a preop assessment when good prior records are available; the value is in the history and risk stratification.
The bottom line
Preop cardiac clearance is one of the fastest, cleanest interactions in cardiology — a focused review with a written deliverable to the surgical team. The virtual format makes it accessible to patients facing a surgery date who cannot wait weeks for a traditional cardiology slot. The work fits the model well, the turnaround is fast, and the surgical team gets exactly what they need to plan the procedure safely.