Expectations and Risks for the Cardiologist

by C. Thea Pitzen

Often cardiac patients, or their surgeons or primary care physicians, may present before a non-cardiac operative procedure requesting “cardiac clearance” for surgery. It is a familiar concept, but perhaps a misnomer. In fact, many cardiologists prefer to avoid the term “cleared” for surgery altogether. Instead, this preoperative evaluation may be best framed as a discussion and consideration of the risks and benefits to the patient.

Certainly, all patients scheduled to undergo non-cardiac surgery should be evaluated for risk of an intraoperative cardiovascular complication. Often, the initial evaluation may be performed by the primary care physician. However, if the patient is under the regular care of a cardiologist – or if the initial evaluation reveals an elevated cardiovascular risk – evaluation by the cardiologist will be required.

Cardiologists are well suited to perform these evaluations, and there are many resources available regarding the medical evaluation itself. But from a legal/risk perspective, there are also a few key points to keep in mind.

• First, clear communication is key. Have an honest conversation with your patient about the risks and benefits of the procedure being considered. Also, be sure to communicate clearly and in writing with the physician requesting “clearance.” Pay close attention to the information requested, and to anything you sign. If you receive a form to return to the physician requesting cardiac clearance, review it carefully before signing – even if a staff member assists in filling it out. If there is pertinent information about your patient that is not included, bring that information to the requesting physician’s attention by adding it to the form, calling the physician, or both. If you communicate by phone, note that in the patient’s chart. Examples of pertinent information might include when you last evaluated the patient, any additional testing or labs needed, and any particular considerations regarding the timing or operative setting for the procedure being planned.
• Second, review the chart and document your preoperative assessment. In addition to examining the patient, review the chart for previous notes or records received from other providers in the course of your treatment that might affect your evaluation of the risks associated with surgery. Document your analysis, as well as your communications with the patient and other physicians. Thorough documentation is a good habit and guards against any future question as to whether your evaluation was appropriate.
• Finally, timing is critical. If you evaluate a patient for surgery but then learn surgery will be delayed for some reason, consider whether there have been any changes in the patient’s health that would affect your evaluation, and communicate that to the patient and the requesting physician. If you provide an initial evaluation but receive a subsequent request or form for that patient (for example, asking to hold a particular medication or to assess a particular condition or medical device), consider the reason for the follow-up request. If necessary, request additional information about the planned procedure, or consider whether another evaluation is necessary so that you can be confident in your preoperative assessment.

This article originally published in Hampton Roads Physician Spring 2019 issue.