🎙️ Episode 41: Stairway to Surgery: Cardiac Clues Before the Cut

🧠 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.

Chapters

• 0:00 Cardiovascular Management Updates
• 0:39 Functional Capacity Assessment Methods
• 1:12 BNP Testing and Stress Test Role
• 1:53 SGLT2 Inhibitors and Troponin Monitoring

Transcript

Speaker 1: 0:11

All right, let's talk about changes and kind of updates in cardiovascular management for non-cardiovascular surgery. Now recommendations are getting a Duke Activity Status Index to dashy Doesn't that sound good? And if it's greater than 34, you can proceed with surgery without further testing. What else can you use? Metabolic equivalence greater than four? What's that? The METs? So what's greater than four? Hey, can you walk up a flight of stairs without going short of breath? That's a good way of checking somebody. Can they go up a flight of stairs? Now, sometimes people don't have a flight of stairs to go up.

Speaker 1: 0:44

Now, if you can't, if poor, unknown functional capacity, it may be reasonable to get a BNP, pro BNP or troponin or all three of the or all two of the above's, bnp and pro BNP About the same Very weak evidence. If elevated, what do you do? Well, they say, get a multidisciplinary team discussion. That's a way of slowing and delaying surgery and getting more people involved in lawsuits. Now, stress tests. Stress tests used to be involved, but you use this for elevated risk, poor or unknown cardiofunction, if high-risk myocardial ischemia, preoperative stress testing and revascularization have not shown to improve outcomes in patients. But the patients with high-risk coronary anatomy were excluded from the research. So these are things to think about Now. They do want you to stop your SGL2 inhibitors, the sodium glucose co-transmitter 2 inhibitors, three to four days prior to minimize a risk for ketoacidosis. And it is reasonable to follow troponins for someone who has a mild cardio injury after non-cardiac surgery. Mins, mins.