In this feature interview, John Ryan, MD, FACC, asks Eiman Jahangir, MD, FACC, consultative cardiologist at Ochsner Medical Center, Hansie Mathelier, MD, FACC, assistant professor at the University of Pennsylvania and Ben Freed MD, FACC, assistant professor at Northwestern University, "What language do you use when providers ask you to "clear a patient" for surgery?"

The interview is the third in a three-part series highlighting the complex clinical issues that are facing early career cardiologists.This article is the third in a three-part series highlighting the complex clinical issues that are facing early career cardiologists. Read part one and part two.

Eiman Jahangir: With the new guidelines combining the intermediate and high-risk categories, I have revised my risk assessment and language in "clearing individuals." I now send the surgeon or anesthesiologist a detailed paragraph stating the following (All text in italics is to be selected based on patient details):

• For low risk individuals: This individual is at low risk for cardiovascular event during the low/moderate/high risk surgery. The revised cardiovascular risk index is <2 and is associated with a <7 percent risk of major cardiovascular events. He/she has the following risk factors (surgery type [undergoing supra-inguinal vascular, intra-peritoneal, or intra-thoracic surgery], history of congestive heart failure, history of ischemic heart disease, history of cerebrovascular disease, pre-operative treatment with insulin, and pre-operative creatinine > 2mg/dL). He/she does have the ability to perform > 4 MET levels of activity and has no active cardiac conditions. He/she may proceed with surgery with no additional cardiac testing or procedures.
• For at elevated risk individuals: This individual is at elevated risk for a low/moderate/high risk surgery. The revised cardiovascular risk index is ≥2 and is associated with a >11 percent risk of major cardiovascular events.
  
  He/she has the following risk factors (surgery type [undergoing supra-inguinal vascular, intra-peritoneal, or intra-thoracic surgery], history of congestive heart failure, history of ischemic heart disease, history of cerebrovascular disease, pre-operative treatment with insulin, and pre-operative creatinine > 2mg/dL). He/she does/does not have the ability to perform > 4 MET levels of activity and does/does not have any active cardiac conditions. He/she may proceed with surgery with the following recommendations: If he/she is on a beta-blocker then I recommend continued use throughout surgery. Close attention should be paid to the peri-operative heart rate and blood pressure.

Hansie Mathelier: Initially when I read that question, I was thinking of the language that I internalize when they ask me to "clear a patient." The language I use is verbal and written. Often, when I talk to the surgical residents, they are calling a consult. I mention to them I don't clear people for surgery. Rather I evaluate and, if necessary, implement measures to prepare higher risk patients for surgery.

When I am writing the assessment for the consult, I first determine if they are low or high risk. Usually, if they are calling for a cardiology consult for preoperative evaluation, the patient is high risk, or it is an evaluation prior to vascular surgery. If the patient is high risk or has potential risk factors for perioperative myocardial infarction, I document that the "patient is at an increased but acceptable risk for surgery."

Ben Freed: Although frequently asked to give a patient "cardiac clearance," I never use this language. For starters, stating that the patient is "clear for surgery" gives both the patient and his/her provider the false hope that no cardiac event will occur during surgery – a promise no cardiologist can guarantee. In addition, giving someone cardiac clearance has no actual meaning and conveys the message that no thoughtful evaluation of the patient was actually performed.

I interpret cardiac clearance to mean cardiovascular risk assessment and will use this language in my evaluation. I follow the 2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery and assess the following:

1. the emergent nature of the surgery,
2. the functional status of the patient,
3. the overall cardiovascular risk of the patient, and
4. the overall risk of the surgery.

I provide my thoughts for each of these categories and whether or not I believe further cardiovascular testing is required prior to surgery. I avoid stating that the patient is low, moderate, or high risk as this is subjective and can be interpreted differently depending on the provider.

This interview was conducted by John Ryan, MD, FACC, assistant professor at the University of Utah.