Subinternship Surgery · Year 4 · from Subinternship Surgery
Case 1: Cardiac Risk Stratification for Non-Cardiac Surgery
Patient Presentation
Demographics: 68-year-old male
Chief Complaint: Right inguinal hernia causing intermittent discomfort
History of Present Illness: Mr. Thompson is referred for elective right inguinal hernia repair. The hernia is reducible and has been present for 6 months. He reports mild discomfort with heavy lifting but no obstructive symptoms. He works part-time as a consultant and walks 2 miles daily without difficulty.
Past Medical History:
- Hypertension (well-controlled)
- Type 2 diabetes mellitus on metformin (HbA1c 7.2%)
- Hyperlipidemia
- Remote history of NSTEMI 4 years ago, treated with PCI to LAD with drug-eluting stent
- Current medications: aspirin 81mg, atorvastatin 40mg, lisinopril 20mg, metformin 1000mg BID
Social History:
- Former smoker, quit 5 years ago (30 pack-years)
- Occasional alcohol
- Lives with wife, independent ADLs
Physical Examination:
- Vitals: BP 132/78, HR 72, BMI 29
- Cardiovascular: Regular rhythm, no murmurs, JVP normal
- Lungs: Clear
- Abdomen: Soft, right inguinal bulge with cough impulse, easily reducible
- Extremities: 1+ peripheral pulses, no edema
Laboratory Studies:
- Creatinine: 1.1 mg/dL
- HbA1c: 7.2%
- ECG: Normal sinus rhythm, no ischemic changes
Clinical Questions
- Calculate this patient's RCRI score and interpret the risk:
RCRI Criteria Assessment:
- High-risk surgery (intraperitoneal, intrathoracic, suprainguinal vascular): NO (inguinal hernia is low-risk)
- History of ischemic heart disease: YES (prior MI, PCI)
- History of heart failure: NO
- History of cerebrovascular disease: NO
- Diabetes requiring insulin: NO (on oral agents only)
- Renal insufficiency (Cr >2.0): NO
RCRI Score: 1 point
- Predicted MACE risk: 0.9%
- Interpretation: Low cardiac risk for this elective procedure
- What is this patient's functional capacity in METs? Does he need further cardiac testing?
Functional Capacity Assessment:
- Walks 2 miles daily without difficulty = >4 METs
- Works part-time, active lifestyle
- No symptoms of angina or dyspnea with exertion
Decision: No additional cardiac testing needed
- Functional capacity exceeds 4 METs
- Asymptomatic on current regimen
- Low-risk surgery
- Stable coronary disease >4 years from intervention
- How should you manage his aspirin perioperatively given his cardiac stent?
Aspirin Management:
- Continue aspirin 81mg throughout the perioperative period
- DES placed 4 years ago - past the high-risk window for stent thrombosis
- Bleeding risk of inguinal hernia repair is low
- Risk of stent thrombosis if aspirin stopped > bleeding risk of continuing
- Document discussion with patient and cardiology if any concerns
- What medication adjustments are needed on the day of surgery?
| Medication | Day of Surgery | |------------|----------------| | Aspirin | Continue | | Atorvastatin | Continue | | Lisinopril | Hold morning of surgery (prevents intraoperative hypotension) | | Metformin | Hold day of surgery (resume when eating and renal function stable) |
Clinical Image
Image: Illustration of coronary artery disease and myocardial infarction. Understanding cardiac history is essential for preoperative risk stratification. Source: Blausen Medical, Wikimedia Commons. License: CC BY 3.0.
Image Attribution: Blausen.com staff (2014). "Medical gallery of Blausen Medical 2014". WikiJournal of Medicine. CC BY 3.0.