What is a case example of preoperative assessment for aortic stenosis (AS) in a noncardiac surgery patient with limited mobility?

Updated: Jul 16, 2021
  • Author: Lindsay A (Finger) Raleigh, MD; Chief Editor: Sheela Pai Cole, MD  more...
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A 67-year-old man presents to the anesthesia preoperative clinic before undergoing elective total knee replacement. His past medical history includes hypertension, diabetes, and hyperlipidemia. He denies any history of angina or heart attacks. He denies experiencing shortness of breath or chest pain with exertion, though he reports that his exercise tolerance is limited by severe knee pain. On examination, the presence of a loud, late-peaking systolic murmur is noted.


This patient has several risk factors for CAD and AS. In addition, he has physical examination findings suggestive of a pathologic murmur. In patients with severe pain that limits mobility, it can be difficult to assess functional capacity or exercise tolerance. Often, patients with AS are diagnosed when cardiac auscultation reveals a systolic murmur. In this case, the elective procedure should be delayed to allow further cardiac workup.

Per the AHA/ACC guideline, when there is an unexplained systolic murmur or symptoms that might be due to AS, TTE is indicated as part of the initial evaluation “to confirm the diagnosis, establish etiology, determine severity, assess hemodynamic consequences” and determine risk stratification prior to noncardiac surgery. [8]

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