One of the main purposes of the preoperative history and physical exam is to identify any preoperative medical comorbidity that may lead to an increased perioperative morbidity or mortality. If comorbidities are identified, the surgeon should obtain medical consultation to ensure that the patient's medical conditions are optimized and stable enough to proceed with surgery at an acceptable risk.
Most gynecologic surgeries fall in the low (<1%) or intermediate (1–5%) risk of cardiac death or nonfatal myocardial infarction (Table 45–1). It is crucial to obtain a careful preoperative history to discover cardiac and/or comorbid diseases that would place the patient in a high surgical risk category. If the patient is found to have active cardiac conditions, such as unstable coronary syndrome, decompensated heart failure, significant arrhythmias, or severe valvular disease, the surgery should be delayed or cancelled (unless emergent), and the patient should be evaluated and treated (Table 45–2). One should also determine if the patient has a prior history of a pacemaker, implantable cardioverter-defibrillator, orthostatic intolerance, or other clinical risk factors that are associated with increased perioperative cardiovascular risk (Table 45–2). If the patient has a history of cardiac disease, any recent change in symptoms must be elicited. In addition, one should record current medications including doses and any use of alcohol, tobacco, and over-the-counter and illicit drugs. The history should also include the patient's functional capacity (Table 45–3). Assessing a person's capacity to perform common daily tasks correlates well with maximum oxygen uptake by treadmill testing.
Table 45–1. Cardiac Risk (Cardiac Death and Nonfatal Myocardial Infarction) for Noncardiac Procedures. |Favorite Table|Download (.pdf)
Table 45–1. Cardiac Risk (Cardiac Death and Nonfatal Myocardial Infarction) for Noncardiac Procedures.
|Risk Stratification||Examples of Procedures|
|High (vascular surgery) (reported risk >5%)|
Aortic and other major vascular surgery
Peripheral vascular surgery
|Intermediate (reported risk 1–5%)|
Head and neck surgery
|Low risk (reported risk <1%)|
Table 45–2. Clinical Risk Factors for Increased Perioperative Cardiovascular Complications (Myocardial Infarction, Heart Failure, Death). |Favorite Table|Download (.pdf)
Table 45–2. Clinical Risk Factors for Increased Perioperative Cardiovascular Complications (Myocardial Infarction, Heart Failure, Death).
|Active cardiac conditions that require intensive management and may result in delay or cancellation of surgery unless the surgery is emergent|
|Unstable coronary syndromes|
|Including unstable or severe angina or recent myocardial infarction (within 30 days)|
|Decompensated heart failure|
|Including NYHA functional class IV or worsening or new-onset heart failure|