Run the List: Perioperative Risk and Management

Episode Date: June 9, 2025
Guest: Dr. Michael Janjigian, Associate Professor of Medicine, NYU; Associate Chief of Medicine, Bellevue Hospital
Hosts: Walker Redd, Emily Gutowski, Navin Kumar, Joyce Zhou, Blake Smith

Overview

This episode of Run the List demystifies perioperative medicine for internal medicine practitioners by systematically breaking down the updated 2024 ACC/AHA guidelines on cardiac risk stratification and perioperative management. The discussion, led by Dr. Michael Janjigian—an expert in inpatient medical consults—focuses on a practical, algorithmic approach, using a case study to illustrate key principles and medication management strategies in the perioperative setting.

Key Discussion Points & Insights

The Importance and Intimidation of Perioperative Medicine

• Perioperative assessments can be intimidating due to the responsibility of “clearing” patients for surgery.
• Many attendings, especially in specialties like cardiology or primary care, frequently conduct preoperative evaluations.
• Understanding risk stratification benefits clinicians' broader skills in risk assessment and management.
• Quote:

  "I think this is actually something that's very important for us to learn to be comfortable with." (Host, 01:27)

Dr. Janjigian’s Stepwise Approach to Perioperative Cardiac Evaluation

Step 1: Does the Patient Need a Pre-op Evaluation?

• Not every surgical candidate requires internal medicine evaluation; depends on age/comorbidities and institution protocols.
• If low-risk (per set criteria), patients can bypass pre-op assessment and be seen directly by anesthesia day of surgery.
• Quote:

  “The first question is, does the patient have risk factors and need to even be evaluated by an internist?” (Dr. Janjigian, 03:56)

Step 2: Is the Surgery Emergent?

• Emergent = loss of life/limb within 2 hours.
• Emergent cases bypass further stratification.
• Examples: ruptured viscous = emergent; hip fracture = urgent, but not emergent.

Step 3: Are There Active Cardiac Conditions?

• Screen for: acute coronary syndrome, unstable arrhythmia, decompensated heart failure.
• If present, pause to address/optimize medically and delay surgery if necessary.
• Memorable moment: Dr. Janjigian highlights picking up subtle clues (e.g., "crackles," "troponin spill") especially in the inpatient setting (04:55).

Step 4: Risk Stratification Using Standardized Tools

• Two recommended tools (per 2024 guidelines):
  • RCRI (Revised Cardiac Risk Index): traditional but declining in use.
  • Gupta Score (MICA – MI Cardiac Arrest): preferred, more streamlined and outcome-relevant.
• Low risk:
  • RCRI score 0–1 or Gupta <1% MACE = may proceed to surgery.
• Elevated risk:
  • RCRI ≥2 or Gupta >1% = further evaluation needed.
• Quote:

  “I think of it like the Latin of risk stratification tools. It's been around forever, but it's becoming less and less useful.” (Dr. Janjigian on RCRI, 06:23)

Step 5: Assess Chronic Disease Risk Modifiers

• Newly explicit in 2024 guidelines.
• Includes severe valvular, congenital heart, or pulmonary hypertension, etc.
• Consult appropriate specialty if present (e.g., pulmonology vs. cardiology).
• Quote:

  “Depending on what the situation is for the patient, you're going to call the correct service.” (Dr. Janjigian, 09:35)

Three Patient Pathways After Risk Stratification (10:00):

1. Low cardiac risk, no modifiers: Proceed to surgery.
2. Chronic disease risk modifiers: Consult subspecialty.
3. Elevated cardiac risk, no modifiers: Continue down the algorithm.

Functional Status – The Role of METs

• 4 METs is the practical cutoff; ability to walk two city streets or a flight of stairs without symptoms indicates adequate functional status.
• If >4 METs: proceed to surgery.
• If <4 METs (due to any reason): further testing/considerations required.
• Clarification:

  “If you can do more than 4 METs, your overall cardiovascular risk is considered acceptable to go to the OR, regardless of what your Gupta score or RCRI was.” (Dr. Janjigian, 11:03)

Latest Guideline Updates: BNP as a Decision Point (12:50–15:07)

• Addition of BNP/NT-proBNP in 2024 (borrowed from Canadian algorithms).
• Low BNP/proBNP (<300): May proceed to surgery even with lower functional status.
• High BNP (>300): Proceed to multidisciplinary discussion about further workup (e.g., echo, possible stress test, or coronary CTA).
• Not always a directive to perform further invasive testing.

Multidisciplinary Decision-Making

• At higher levels of risk, coordination with anesthesia, surgery, cardiology/pulmonology is crucial.
• Shared decision-making with the patient emphasized when risks, testing, and delays are considered.
• Quote:

  “When we get to this part of the algorithm, we really are picking up the phone and we're calling our colleagues…also for shared decision making.” (Dr. Janjigian, 18:57)

Practical Case Application (19:39–22:03)

Summary of Case:

• 60yo male, controlled hypertension (amlodipine + ramipril), scheduled for middle ear exploration.
• Good functional status, no unstable cardiac disease or chronic risk modifiers.
• Gupta score = 0.1% → low risk.

Medication Management:

• Calcium channel blockers: Continue perioperatively; safe.
• ACE/ARBs: May cause intraoperative hypotension—data show hypotension but not worse outcomes.
  • For most, reasonable to continue, especially if:
    • Well-controlled hypertension and minor surgery.
    • Heart failure patient (for neurohormonal benefit).
  • For major/prolonged surgery, reasonable to hold day of.
• Quote:

  “Calcium channel blockers have been shown to be very safe around the time of surgery... Continuing calcium channel blockers has been shown to be very safe. So that's a pretty easy one—we continue.” (Dr. Janjigian, 20:34)
  “For this patient...it was recommended that he continued both of those antihypertensives throughout the perioperative period, including on the morning of surgery.” (Dr. Janjigian, 21:51)

Notable Quotes & Memorable Moments

• On “clearance”:

  “We don't love to use the word clearance...but that's really ultimately what the surgeons want out of us.” (Dr. Janjigian, 03:23)

• On the heart of the evaluation:

  “Really the backbone of this is going to be the ACC/AHA guidelines.” (Dr. Janjigian, 03:36)

• On evolving algorithms:

  “What is different about the 2024 algorithm compared to prior is that we're now thinking about chronic disease risk modifiers before, it was just implicit...” (Dr. Janjigian, 08:50)

• On functional assessment in practice:

  “We live in New York... When you get to communities where everybody's driving everywhere, it's probably going to be a little bit harder to determine their functional status.” (Dr. Janjigian, 11:31)

• On practical medication wisdom:

  “Our goal is really to avoid hypertension and hypotension.” (Dr. Janjigian, 20:28)

Timestamps for Key Segments

| Topic | Timestamp | |-----------------------------------------------|--------------| | Perioperative evaluation as “primary care” | 03:06 | | Risk stratification tools (RCRI, Gupta) | 06:03–08:03 | | Chronic disease modifiers (2024 update) | 08:50–09:35 | | Functional status (METs explained) | 10:45–11:58 | | BNP in the new algorithm | 12:50–15:07 | | Multidisciplinary decision-making | 18:57–19:25 | | Case summary and medication management | 19:39–22:03 |

Conclusion

Dr. Janjigian delivers a clear, stepwise, and guideline-driven approach to perioperative risk assessment, emphasizing collaboration, contextual thinking, and nuanced medication management. This episode serves as a practical reference and confidence-builder for trainees and clinicians learning to “run the list” for preoperative patients.

End of summary.