A 56 years old man is scheduled for an elective transurethral resection of the prostate. He is a known diabetic and is on insulin for the same. He also has angina on moderate to severe exertion since the past 6 months. He was taking beta blockers and long acting nitrates for the angina and his symptoms were under fair control.

 (1)   During preoperative evaluation this man would be classified as:

 (a)    Having a major clinical predictor for cardiac disease

(b)   Having a minor clinical predictor for cardiac disease

(c)    Having an intermediate clinical predictor for cardiac disease

(d)   Having no significant predictors for cardiac disease

Answer: The answer is (c). According to the American Heart Association/American College of Cardiology guidelines for preoperative evaulation of cardiac patients for non-cardiac surgery, this man who has diabetes mellitus and mild exertional angina pectoris is classified as having intermediate predictor of cardiac disease.

(2)   He was subject to a cardiac stress test on a treadmill and was found to have more than 7 METs exercise tolerance. Considering his surgery, which is of intermediate surgical risk, what would be the next step in his assessment?

 (a)    A coronary angiogram to rule out critical stenosis

(b)   An echocardiogram to evaluate his Left Ventricular function

(c)    A Nuclear scan to non-invasively evaluate his myocardial perfusion

(d)   No further work up from cardiac point of view.

 Answer: The answer is (d). Given that the man has good exercise tolerance on the cardiac stress test, and that he is going in for an intermediate risk surgery, the American Heart Association/American College of Cardiology guidelines allow proceeding with surgery with no further work up at this point. He has to be evaluated and assessed for cardiac risk again post operatively.