Date:
Patient: [Patient Name], [Age], [Medical Record Number]
Attending: [Physician Name]
I. Preoperative Assessment
Reason for Surgery: Briefly describe the planned non-cardiac surgery.
Past Medical History:
Document any existing cardiac conditions (ischemic heart disease, heart failure, arrhythmias, valvular heart disease)
Other relevant medical history (diabetes, chronic obstructive pulmonary disease [COPD], chronic kidney disease [CKD])
Risk Factors:
Identify risk factors for perioperative cardiac complications using a validated scoring system (e.g., Revised Cardiac Risk Index [RCRI]).
Consider additional risk factors like advanced age, emergency surgery, and poor functional status.
Medications: List current medications, including cardiovascular medications.
II. Cardiac Evaluation
Physical Exam: Document any abnormal cardiovascular findings (e.g., murmurs, S3 gallop).
Investigations (ordered based on risk stratification):
Electrocardiogram (ECG) – to assess for arrhythmias or prior myocardial infarction.
Chest X-ray – to evaluate for pulmonary congestion suggestive of heart failure.
Additional tests may be considered in high-risk patients:
Echocardiogram – to assess cardiac function and valvular structure.
Stress testing – to evaluate for exercise tolerance and potential ischemia.
III. Risk Stratification
Based on the RCRI score and other clinical factors, categorize the patient’s overall cardiac risk for surgery (low, moderate, high).
IV. Perioperative Management Plan
Medical Optimization: Address any pre-existing cardiac conditions to optimize medical management before surgery.
Consider medication adjustments (e.g., beta-blockers, statins).
Communication: Communicate the risk assessment and plan with the surgeon and anesthesia team.
Intraoperative Monitoring: Plan for appropriate monitoring during surgery (ECG, pulse oximetry).
V. Postoperative Management
Monitoring: Closely monitor vital signs and for signs of cardiac complications (chest pain, shortness of breath).
Pain Management: Adequate pain control can improve respiratory function and decrease cardiac workload.
Continuation of Medical Therapy: Continue medications as tolerated unless otherwise directed.
VI. Follow-up
Schedule for follow-up appointment to assess recovery and address any ongoing concerns.
VII. Notes
Document any additional information relevant to the patient’s perioperative cardiac care, such as:
Consultations with cardiologists or other specialists.
Specific discharge instructions regarding medications and activity limitations.
Disclaimer: This information is for educational purposes only and should not be interpreted as medical advice. Please consult with a qualified healthcare professional for the management of patients undergoing non-cardiac surgery.