Preoperative Cardiac Risk Assessment Note (Noncardiac Surgery)

Date/Time: [Date and time of note]

Patient: [Patient name and identifiers]

Referring Clinician: [Name, role, service]

Reason for Referral: [Reason for cardiac evaluation]

(This consultation estimates perioperative cardiovascular risk and provides risk-mitigation recommendations; it is not an authorization to proceed.)

Surgical Context

• Planned procedure: [Procedure name / unknown]
• Surgeon/Specialty: [Surgeon name and specialty]
• Planned date: [Date / TBD]
• Urgency: [emergency / urgent / time-sensitive / elective]
• Anesthesia plan: [general / regional / MAC / unknown]
• Setting: [inpatient / outpatient / unknown]
• Neuraxial anesthesia anticipated: [yes / no / unclear]

(This section drives all downstream logic. If procedure or urgency is unknown, explicitly state this and note that risk estimates are provisional.)

Reason for Cardiac Evaluation

[Concise reason for consult] (One to two sentences; examples: general risk stratification, optimization of known disease, abnormal testing, antithrombotic management.)

Cardiovascular History and Symptoms

[Summary of current cardiac symptoms and stability] (Address chest pain, dyspnea, orthopnea, edema, syncope, and palpitations when present; note onset, exertional component, and current stability.)

• Coronary artery disease: [Prior MI, PCI with dates/stent type, CABG, last ischemic evaluation]
• Heart failure: [EF, NYHA class, recent exacerbations, current volume status]
• Valvular disease: [Lesion(s), severity, symptoms, last echocardiogram date]
• Arrhythmias/conduction: [Type, burden, rate/rhythm control, anticoagulation indication]
• Cardiac devices: [Device type, pacing dependence, last interrogation]
• Other relevant comorbidities: [CKD / diabetes / severe OSA / pulmonary hypertension / none]

(Include only conditions present; omit inapplicable items.)

Functional Capacity

• Assessment method: [History-based activity inventory / formal testing]
• Activities: [Specific activities and whether limited by symptoms]
• Estimated METs: [≥4 METs / <4 METs / indeterminate]
• Limiting factor: [cardiac / pulmonary / orthopedic / neurologic / deconditioning / unclear]

(If indeterminate, state reason; do not infer functional capacity without basis.)

Medications

[List current cardiovascular and relevant medications with doses]

• Beta blocker: [Agent/dose or none] — [continue / hold]
• Statin: [Agent/dose or none] — [continue / initiate]
• ACEi/ARB/ARNI: [Agent/dose or none] — [continue / hold morning of surgery / hold 24 hours prior]; restart [timing]
• Diuretics: [Agent/dose or none] — [continue / hold morning of surgery]; restart [timing]
• Anticoagulant: [Agent/dose or none] — last dose [date/time], hold [interval], bridging [yes / no], neuraxial considerations [yes / no], restart [criteria], final plan coordinated by [cardiology / surgery / anesthesia / anticoagulation clinic]
• Antiplatelet therapy: [Aspirin / P2Y12 inhibitor / dual / none] — [continue / hold]; indication [primary / secondary prevention]; stent history [details if relevant]; restart [criteria]
• SGLT2 inhibitor: [Agent/dose or none] — stop 3–4 days pre-op; restart when eating, stable, and not ketotic
• Other cardiac medications: [Nitrates, antiarrhythmics, pulmonary vasodilators] — [perioperative instructions]

(Include only medication classes that apply. Address high-priority classes explicitly when present.)

Allergies: [Relevant allergies; emphasize antiplatelet/anticoagulant reactions and contrast allergy]

Examination

• Vitals: BP [value], HR [value], SpO2 [value], weight [value if HF present]
• Cardiac: [Rhythm, rate, murmurs with grade/location, gallops/rubs, JVP]
• Lungs: [Breath sounds, rales/wheezes]
• Extremities: [Edema, pulses, perfusion]
• Volume status: [euvolemic / hypovolemic / hypervolemic]

Data Reviewed

• ECG: [Date] — [rhythm, ischemic changes, conduction abnormalities]
• Echocardiogram: [Date] — [EF, valve lesions/severity, pulmonary pressures]
• Stress testing: [Type and date] — [ischemia present/absent, functional capacity achieved]
• Coronary angiography: [Date] — [key findings/interventions]
• Device interrogation: [Date] — [battery status, pacing dependence, arrhythmia events]
• Laboratory data: [Creatinine, hemoglobin, BNP/NT-proBNP with dates]
• Records pending: [Items requested and not yet received]

(Include only studies that were reviewed or are pending. Omit inapplicable items.)

Risk Stratification

• Procedure risk: [low / intermediate / high] (State assumptions if procedure details are incomplete.)
• Patient risk: [Tool used: RCRI / NSQIP / other] — inputs: [key variables], estimated MACE: [risk category and numeric estimate]
• Unstable or high-impact conditions: [none / acute coronary syndrome / decompensated HF / severe symptomatic valvular disease / significant arrhythmia]

(If unstable conditions are present, specify recommended optimization or deferral steps.)

Assessment

(Problem-oriented summary; one to two sentences per problem addressing current status, stability, and operative relevance. Include only applicable problems.)

• [Cardiac problem 1]: [Status and operative relevance]
• [Cardiac problem 2]: [Status and operative relevance]
• [Additional problems as applicable]: [Status and operative relevance]

Recommendations

Optimization status: From a cardiovascular standpoint, [patient is optimized / patient is not yet optimized] for the planned surgery.

• Preoperative testing: [No additional testing recommended / specific test recommended with indication, how result would change management, and timing]
• Medication management: [Concise summary of perioperative medication actions; specify who coordinates antithrombotic plan if not finalized]
• Hemodynamic goals: [BP targets, HR/rate control targets, volume goals]
• Perioperative monitoring: [Standard / telemetry / invasive monitoring / postoperative troponin surveillance] (Include indications and duration.)
• Device management: [Magnet use / reprogram pre- and post-op / coordinate with device team]
• Postoperative care: [Restart timelines for held medications, cardiology follow-up timing, triggers for urgent evaluation]

(Include only applicable items. Omit device management if no device present.)

Communication and Disposition

• Patient discussion: [Risk discussion summary]
• Surgical/anesthesia team: [Recommendations conveyed and responsible parties]
• Disposition: [proceed / proceed with precautions / defer pending optimization or testing]