Episode Description
🧠 Clinical Context:
You're prepping a patient for non-cardiac surgery—what's their cardiovascular risk? Turns out, it’s not always about echo reports or cath results. It starts with a stairs test (sort of).
- Duke Activity Status Index (DASI) and METs >4 can tell you if the heart's got enough reserve.
- 🚶♂️ “Can you walk up a flight of stairs without gasping?” If yes, you’re likely good to go!
- If functional status is poor or unknown, consider labs:
- BNP, pro-BNP, or troponin — but evidence is weak.
- Elevated? Time to huddle with a multidisciplinary team (or at least buy time for the patient and lawyer to meet).
🧪 Risk Tools, Not Rituals:
- Stress testing isn’t reflexively helpful anymore.
- Reserved for high-risk anatomy or major ischemia concerns.
- Studies show no outcome improvement in most cases.
- Important caveat: those with severe CAD were excluded from trials!
🧊 Meds to Pause:
- SGLT2 Inhibitors (dapagliflozin, empagliflozin):
🔴 Stop 3–4 days pre-op to avoid euglycemic ketoacidosis. - GLP-1 Agonists:
⏸️ Hold 1 week before due to risk of delayed gastric emptying, aspiration, and nausea under anesthesia.
🫀 Post-op Cardiac Surveillance:
- Watch for MINS – Myocardial Injury after Noncardiac Surgery
- Troponin trending may help spot silent ischemia post-op.
- Elevated levels? 🧠 Consider further cardio eval, especially in high-risk patients.
🧩 Clinical Takeaway:
Modern pre-op cardiac clearance is about functional fitness, thoughtful labs, and smart medication pauses. Don’t just tick boxes—evaluate risk in context. And yes, if grandma can climb stairs without wheezing, she might just be ready for her hip replacement.