#475 Perioperative Update with Dr. Avital O’Glasser

Summary

The Curbsiders Internal Medicine Podcast #475: Perioperative Update with Dr. Avital O’Glasser

Main Theme & Purpose

This lively and in-depth episode brings back perioperative medicine expert Dr. Avital O’Glasser to break down the key updates in the 2024 ACC/AHA perioperative guidelines. The episode arms internists and hospitalists with practical advice on risk stratification, inter-specialty communication, preoperative medication management (including GLP-1s, SGLT2 inhibitors, ACE/ARBs), frailty, appropriateness of testing, biomarkers, perioperative hypertension, NPO guidelines, and the complex art of optimizing patients for surgery. The hosts utilize typical Curbsiders humor amid high-yield clinical pearls and patient-centered wisdom.

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Key Discussion Points & Insights

1. The Role of the Preoperative Assessment—"Avoid the C Word"

• The term "clearance" is discouraged; focus instead on a holistic preoperative assessment—not a one-and-done checklist.
• The internist's perioperative role is to quantify and qualify known comorbid conditions (07:10), empower patients, and coordinate optimal care throughout the surgical trajectory.
• Quote [07:10]:

  "The preop assessment... is a chance to learn about a patient, not just generate a risk assessment... but also to empower their perioperative care. It’s the entire spectrum."
  — Dr. Avital O’Glasser

2. Navigating Routine Testing Requests from Surgeons

• The new guidelines (2024 ACC/AHA) reinforce the principle that routine stress tests, EKGs, echos, and PFTs are generally not indicated unless specific clinical indications exist.
• Advocacy is needed to push back on low-value testing, citing evidence and fostering collegial dialogue.
• Institutional inertia and outdated protocols commonly drive unnecessary testing (such as pre-op coags for cataracts or neurosurgery).
• Quote [13:42]:

  “Often those mandated pre-op tests are institutional inertia... Sometimes the best thing to do is just get it done if surgery will be canceled otherwise, but then tackle the system for future patients.”
  — Dr. Avital O’Glasser

3. Communicating Assessment Results: Words Matter!

• Use precise, actionable phrases:
  • “This patient is stable and optimized for this surgery.”
  • “Is further testing needed? Yes/No” and “Is further optimization needed? Yes/No.” (19:34)
  • For complex patients: “risk appropriate” or “risk prohibitive.”
• Quote [19:34]:

  “My preferred charting style is, ‘This patient is, or is not, stable and optimized for this surgery.’”
  — Dr. Avital O’Glasser

4. Risk Calculators: RCRI, MICA/Gupta, and Risk Modifiers

• Know your tool: RCRI, Gupta (MICA), and ACS NSQIP predict different outcomes (MI vs. broader cardiovascular events).
• Prefer MICA/Gupta in the U.S. due to contemporary derivation and more robust databases.
• New ACC/AHA guidelines suggest using Gupta >1% or RCRI >1 (no percentage) as thresholds for further workup (23:57).
• Add risk modifiers: Frailty, severe valve disease, PH, prior coronary revascularization, congenital heart disease, ICDs, recent stroke.
• Quote [25:27]:

  “There are patients who will fall out of the population model and need unique risk consideration... Frailty is one of the modifiers.”
  — Dr. Avital O’Glasser

5. Frailty: Assessment & Implications

• Routine frailty screening now Class II recommendation in guidelines.
• Frailty ≠ comorbidity ≠ disability, but can overlap.
• Tools: Dr. O’Glasser prefers Edmonton Frail Scale, paired with the Mini-Cog for cognitive assessment (32:27).
• Screening for frailty allows for:
  • Prehabilitation.
  • Possible surgical postponement or even cancellation if risks outweigh benefits.
  • Tailoring post-op planning and family involvement.
• Quote [28:16]:

  “Why are we predicting? We’re trying to predict so we can try to prevent.”
  — Dr. Avital O’Glasser

6. OSA and Pulmonary Optimization

• Routine pre-op PFTs rarely indicated—except thoracic surgery or undiagnosed dyspnea.
• OSA recognition is crucial; positive STOP-BANG requires targeted risk mitigation but surgery rarely delayed for formal sleep study (44:13).
• Optimize OSA: Ensure proper use of CPAP, consider level of monitoring, and surgical procedure considerations (e.g., contraindication to CPAP post-op in some cases).

7. Medication Management: ACE/ARBs, SGLT2i, GLP-1s

ACE/ARBs

• Nuanced, individualized. Hold 24 hours prior for non-cardiac, low-risk patients prone to intra-op hypotension (especially if well controlled), but continue in HFrEF (50:08).
• Quote [50:08]:

  “At this juncture, we’re at flip-a-coin... individualized decision-making is key.”
  — Dr. Avital O’Glasser

SGLT2 Inhibitors

• Hold for 3 days before elective surgery due to DKA risk.
• In patients with heart failure (and no DM), weigh the risk of volume overload; may continue up to day of surgery based on patient stability (70:50).

GLP-1 Agonists

• Concern for delayed gastric emptying/aspiration—growing trend to hold for up to 1 week pre-op, but evidence evolving and context-specific (69:18).

8. Perioperative Hypertension: When to Postpone?

• Guidelines advise deferring elective surgery only if BP >180/110 mmHg (consistent with Drs. Merle/Weitz).
• Gather home BP trends; aim for <150 systolic for comfort if time allows, but don’t overtighten control abruptly (57:40).

9. NPO Guidelines & Institutional Inertia

• Strong evidence for clear liquids up until 2 hours before surgery, but most U.S. institutions lag behind due to dogma.
• Hydrated, carbohydrate-replete patients do better; ERAS protocols advocate for liberalized pre-op fluid intake (65:17).

10. Cardiac Biomarkers & Perioperative Surveillance

• BNP/NT-proBNP: Class IIa—can help in intermediate/high cardiac risk and uncertainty about HF status or functional capacity.
• Troponin: Class IIb—routine pre-op troponin for everyone not recommended; more for select high-risk patients.
• Pre-op baselines can distinguish chronic elevations from acute events post-op; more valuable if you’re planning post-op troponin surveillance (74:24, 80:17).
• MENs (Myocardial injury after non-cardiac surgery): Prognostic significance for increased risk of cardiovascular events—ensure patients receive "teachable moment" interventions (statin, ASA in recovery phase, tobacco cessation, etc.)

11. Post-Op Atrial Fibrillation

• Do NOT “forgive” transient post-op AFib—associated with increased long-term risk of AFib and stroke.
• Communicate events clearly to the outpatient team; consider extended ambulatory monitoring, appropriate anticoagulation per guideline risk stratification (89:36).

12. Incidental AFib Discovered Pre-op

• Assess stability, symptoms, and underlying cause (TSH, metabolic panel), and tailor further testing and management to surgical urgency and risk.
• For stable, asymptomatic, rate-controlled patients with low-risk surgery, often proceed with close post-op follow-up.

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Notable Quotes & Memorable Moments

• “Perioperative Medicine… is so much more than just a checkbox in the medical record. Make it relational rather than transactional.” (10:07, Dr. O’Glasser)

• “If you walk into the exam room and think, ‘If I sneeze this patient will break a hip’—that’s frailty!” (28:16)

• “Black coffee counts as a clear liquid… if you can read newsprint through it, it counts.” (65:09, Dr. O’Glasser)

• “If you have a STOP-BANG of 7 and AFib… you should be getting a sleep study—but for elective surgery, I almost never delay for it.” (44:13)

• On routine pre-op testing: “We have mounds of data—this is wasteful, does not change management, and costs the healthcare system millions.” (10:07)

• “I use the Edmonton Frail Scale… all of it except the clock draw can be done unassisted. It’s very patient-centered.” (32:27, Dr. O’Glasser)

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Timestamps for Key Segments

• 06:00 – Introduction to pre-op approach and avoiding "clearance"
• 09:30 – Discussing and negotiating routine pre-op test requests
• 19:34 – What to write in your operative note (stable, optimized, etc.)
• 21:31 – Strengths and weaknesses of risk calculators (RCRI vs MICA/Gupta/NSQIP)
• 25:27 – The value of risk modifiers including frailty
• 28:16 – Frailty: Measurement and clinical application
• 32:27 – Dr. O’Glasser’s preferred tools for measuring frailty
• 44:13 – OSA management and pulmonary risk assessment
• 48:35 – ACEs/ARBs perioperative management, guideline update
• 56:40 – Perioperative hypertension thresholds and management
• 62:42 – NPO “except meds” dogma and real evidence
• 65:09 – What counts as a “clear liquid”
• 70:31 – GLP-1 and SGLT2i peri-op management
• 74:24 – Cardiac biomarkers and the use of troponins/BNP before surgery
• 82:19 – MENs (Myocardial injury after non-cardiac surgery), implications
• 89:36 – Approach to post-op AFib and evolving recommendations
• 92:28 – How to handle pre-op incidental new-onset AFib
• 96:09 – Take-home pearls: moving toward holistic, patient-centered perioperative care

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Take-Home Pearls

• Stop saying “clearance”—ask how you can empower the patient’s safest journey, including pre-, intra-, and post-op phases.
• Don’t order routine pre-op tests unless there’s a clear clinical indication; push back on institutional inertia.
• Use concise, clear, and actionable language in your documentation.
• Choose risk calculators fitting your practice (MICA/Gupta), but always integrate clinical judgment and risk modifiers—especially frailty.
• Screen for frailty; intervene when possible, pause or cancel surgery when appropriate, and involve family/support networks in planning.
• Manage perioperative medications individually—ACE/ARBs, SGLT2i, GLP-1s, and antihypertensives all require nuanced approach based on patient and procedure.
• Liberalize NPO instructions where possible: clear liquids up to 2 hours pre-op is best practice.
• Incorporate biomarker data as adjuncts—be aware of institutional capacity to respond to abnormal results.
• Never “forgive” post-op AFib or MENs—these signal increased long-term risk. Communicate to the outpatient team for risk reduction.
• Zoom out from cardiac risk—pulmonary, hematologic, neuropsychiatric, substance use, and social risk factors profoundly impact perioperative outcomes.

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For Further Reference

• Check Figure 1 & 6 of the 2024 ACC/AHA Perioperative Guidelines for stepwise risk stratification and post-op troponin evaluation algorithms.
• The “Things We Do for No Reason” article on NPO after midnight (recommended resource from Dr. O’Glasser).
• Enhanced Recovery After Surgery (ERAS) protocols for guidance on fluids, nutrition, and recovery-acceleration pathways.

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Hosts: Dr. Matthew Watto, Dr. Paul Nelson Williams, Dr. Paul Wirtz
Guest: Dr. Avital O’Glasser
Date: March 17, 2025

“Knowledge is empowering, and knowing what I need to learn about you will help on the day of surgery, in the OR, and beyond.”
— Dr. Avital O’Glasser (99:42)

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Episode available for CME credit at curbsiders.vcuhealth.org.

Transcript

[Sponsor/Ad Announcer]

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[Dr. Matthew Frank Watto]

Cool [e-mail] curbsiders Paul, I don't have a pun for you. Do you have one?

[Dr. Paul Nelson Williams]

No, not a pun Wado. But I wanted to share an anecdote. I actually I had to go to the urgent care center last week a little bit nerve wracking. I swallowed a whole bunch of Scrabble tiles and the doctor told me that my next trip to the bathroom could spell disaster. Thank you to cheeseburger.com.

[Dr. Avital Oglassar]

The curbsiders podcast is for entertainment, education and information purposes only and the topics discussed should not.

[Dr. Paul Nelson Williams]

Be used solely to diagnose, treat, cure or prevent any diseases or conditions. For the more the views and statements expressed on this podcast are solely those.

[Dr. Avital Oglassar]

Of those and should not be interpreted.

[Dr. Paul Nelson Williams]

Perfect official policy or position of any entity aside from possibly cash like more.

[Dr. Avital Oglassar]

Hospital and affiliate outreach programs, if indeed there are any. In fact there are non pretty much we are responsible. If you screw up.

[Dr. Paul Nelson Williams]

You should always do your own homework.

[Dr. Avital Oglassar]

And let us know when. We're welcome.

[Dr. Matthew Frank Watto]

Welcome back to the curbsiders. I'm Dr. Matthew Frank Waddo, here with my great friend and America's primary care physician, surely the primary care physician, Dr. Paul Nelson Williams.

[Dr. Paul Nelson Williams]

Yep, just sitting in my own shame. Feel real bad. Matt, how are you feeling?

[Dr. Matthew Frank Watto]

Feeling bad because of the pun? Is that what you're saying?

[Dr. Paul Nelson Williams]

Mostly that, yeah, it was a good one.

[Dr. Matthew Frank Watto]

Today we have a returning guest, our chief of Perioperative medicine at Kashlak Memorial Hospital, Dr. Avital Oglassar. And we're talking about the most recent updates to the Accaha guidelines which came out in 2024. A lot of stuff in there that we'll talk about and we're gonna tell you more about our guests in a second. But before we do that, Paul, would you remind us what is it we do on the show? And please introduce our esteemed co host for this episode.

[Dr. Paul Nelson Williams]

Sure, Matt. As per usual, we are the Internal Medicine Podcast. We use expert interviews to bring you clinical pearls and practice changing knowledge. As you mentioned, we are joined by Dr. Paul Wirtz, wunderkind writer and producer of this episode and all around my soon to be replacement. I look forward to it. Paul, how are you?

[Dr. Paul Wirtz]

I am doing great. Just happy to help clarify a topic that has been long confusing for all internists everywhere.

[Dr. Paul Nelson Williams]

And while you're on this fantastic role, why don't let you tell us a little bit about who we talk to. I think she's probably ready for the Is it the five Timer jacket yet, Matt? I haven't actually tallied up how many appearances she's had, but she might be ready for her smoking jacket.

[Dr. Matthew Frank Watto]

Yeah, she's easily been on five times, so, yeah, I think so.

[Dr. Paul Wirtz]

So, just a reminder, Dr. O. Glaser is a hospitalist and professor of medicine within the Division of Hospital Medicine, Department of Medicine and Department of Anesthesiology and Perioperative Medicine at Oregon Health and Science University, or ohsu. Her clinical practice focus is perioperative medicine, and she is the medical director of OHSU's Preoperative Medicine Clinic. She is passionate about multidisciplinary, comprehensive practice of perioperative medicine. As an internist, she is very active at the institutional level as well as the international scale, including serving as president of the Society for Perioperative Assessment and Quality Improvement. She is the Honorary Chief of Perioperative Medicine at the esteemed Kashlag Memorial Hospital, and tonight she teaches us all the tips and tricks regarding perioperative medicine, including highlights from the 2024 ACC AHA perioperative guidelines. So without further ado, let's get to it.

[Dr. Matthew Frank Watto]

Yeah, and I would mention we talk about GLP1s. We talk about biomarkers. She tells us what we should write in the notes to make sure we're communicating well with the surgeons. We talk about, can you have clear liquids before. And we have some. Some of our patrons called in with some questions directly. So it's a really fun episode. Can't wait for y' all to hear it. And a reminder that this, in most episodes, will be available for CME credit for all health professionals through VCU Health at curbsiders.vcuhealth.org Avi, welcome back to the show. It has been way too long. You are our chief of Perioperative Medicine, and we're gonna talk all about that. But first, what's a recent hobby or interest that you've been into?

[Dr. Avital Oglassar]

Oh, gosh, Recent, I would say, is blitzing through the Iron Flame series. Is that countless Flame?

[Dr. Matthew Frank Watto]

I don't know what that is.

[Dr. Avital Oglassar]

So it's Dragon Smut. Can I say smut on this podcast? Sure, sure, sure.

[Dr. Paul Nelson Williams]

I wish that you would.

[Dr. Avital Oglassar]

Avi Paul's like, there's a lot to unpack. I've known Avi for, like, how many years Seven, eight years. I really enjoy reading. And as bandwidth shifts on the day to day and week by week basis, I cycle through fiction, nonfiction, cerebral fiction and nonfiction. And then really, this is a fantasy series that many in my family have been waiting a long time for me to pick up. And the third one just came out, so I. I read all three, three books in, in January. Not sure how I pulled that off given how busy January was, but I read all of them and really enjoyed them. And now my Instagram feed just keeps giving me like great fan stuff.

[Dr. Matthew Frank Watto]

Do we think Paul Williams would like this?

[Dr. Avital Oglassar]

Oh, are we doing an over under? I'm gonna go with yes.

[Dr. Paul Nelson Williams]

Who's to say we'll never know. I've been working on the same book for the past three months.

[Dr. Avital Oglassar]

So we will follow up at acp. There's gonna be a quiz.

[Dr. Matthew Frank Watto]

Yeah, Bob, I'm reading a Neal Stephenson book right now. That's a thousand pages. It's gonna take me like 3 months to read it.

[Dr. Paul Nelson Williams]

Yeah, I can't remember if we talked about this on Patreon. I'm doing the Shining Sword, the Love Grossman novel about the King Arthur legend. That is the family Bible size, which I'm enjoying, but it is dense, so it's going to be a minute before I move on.

[Dr. Matthew Frank Watto]

Yeah, it took me a while. Okay. All right, well, we have with us another Paul and Wirtz. Can you read us the first case from Kashlak?

[Dr. Paul Wirtz]

Absolutely. So omar is a 77 year old male with a complex medical history, including OSA on CPAP, CAD with a CABG 20 years ago. He's now on aspirin and rosuvastatin. He's got weight, controlled atrial fibrillation on diltiazem, extended release and dabigatran. He's got Class 2 obesity, recently started on tirzepatide. He's got hypertension on lisinopril and CLL undergoing active surveillance. So he presents today for a preoperative evaluation for cholecystectomy. After a recent hospitalization for cholidochelethiasis treated with ERCP, his surgeon has requested clearance and including labs, PFTs, EKG, stress tests and echocardiogram. So in general, I was just hoping to talk through how you would approach the preoperative patient, particularly the assessment of their functional status, the status of their comorbidities, and how you reconcile this with the request by the surgeon.

[Dr. Avital Oglassar]

Yeah, so I really like how you introduced the questions for this case. I heard the C word, but we definitely avoid C word.

[Dr. Matthew Frank Watto]

Oh, that's clearance. I got you. Sorry, I thought I miss something.

[Dr. Avital Oglassar]

C word for me, really? The pre op assessment, as you very, very appropriately called it, not the Visit for the HNP within 30 days. This is a chance to learn about a patient, not just learn about a patient and spit out or generate a risk assessment from one of our many validated risk calculators, but also to empower their perioperative care. And I love using the term empowered. I use it very liberally with patients myself. Like why am I here? I said I am here to help empower your safest care possible. And it's not just the operating room itself, it is the entire spectrum. Someone may only be in the operating room for three or four hours, but they also have X number of days they might be inpatient recovery and X number of weeks to months to over a year that their recovery trajectory is unfolding in the outpatient setting. So it's not just about am I going to have my surgery canceled in the PACU on the morning of surgery, but it's really how am I going to help be part of your care team and facilitate your perioperative journey through the healthcare system. So I use a couple of mantras liberally with my trainees, with my staff, with patients as well. And I like to say that our role is to quantify and qualify the known comorbid conditions. So you've already given me some information about the status of his coronary disease, his remote revascularization history, his med package. I don't know about his functional capacity yet. I don't know about his symptoms yet. With his cll, like what are his counts? Is he on a therapy? So it's not just a static like pull it in from the electronic health record. Here's your problem list that hasn't been cleaned up in 20 years.

[Dr. Matthew Frank Watto]

Unless it's a Paul Williams patient, absolutely.

[Dr. Avital Oglassar]

That's going to be pristine. Yeah. Oh, I would pre op any of Paul's patients, no questions asked. Can I pre op your cats? That's a long story. Tangent. And how do I really make sure that we have information to take care of you in the operating room? My anesthesiologist colleagues are going to take care of you in the operating room. And then post op, what are the risk mitigation steps? What am I worried about? As a post op complication that's at a non negligible risk, how are we going to risk mitigate that?

[Dr. Matthew Frank Watto]

And Avi, this is not a straightforward one. Right. This guy has a Lot of comorbidities. He's on aspirin, he's on dabigatran, he has cll, he's on blood pressure medications, an ACE inhibitor. So, so much to talk about here, but maybe first we'll ask about the the surgeon is just directly requesting PFTs, labs, EKG, stress test, echo. Maybe we agree with some of that, maybe we don't. So how do you handle that? I know we've talked to you about this, but it's been years, so how do you handle this? If you say some of this testing may be appropriate, some of it's not to the surgical colleague, just in a. What's a diplomatic way to go about this?

[Dr. Avital Oglassar]

Yeah, I think the really important thing to emphasize is this is not just a static. You go, I'm doing air quotes on a podcast. You get your H and P within 30 days and then it's a one and done checkbox. Pre op medicine Perioperative medicine is so much more than just a checkbox in the medical record. And part of the reason I love doing this in a dedicated preoperative medicine clinic at an academic institution is that it affords us the opportunity to build relationships and build lines of communication. And I know that that is something that makes this niche within medicine and anesthesiology and other domains sometimes very, very challenging for people who are in private practice or in the community setting. But when you have that opportunity, I would say absolutely, make it a discussion, make it relational rather than transactional and say, hey, just so you know, based on my assessment, thank you for sending this patient to me based on my very granular holistic assessment and the guidelines, and we have brand new guidelines that have been long awaited that came out a few months ago, say the evidence does not support a stress test or they do not have indications for a pre op stress test because X, Y, Z, make it a teachable moment. And maybe if you feel like you're getting ongoing pushback, it's what, five, 30 at night, my time? I'm going to channel Ted Lasso. Finally today, be curious, not judgmental. Maybe say what? What? Is there something that you're worried about that I'm missing? If somebody says, oh, I think this patient needs an echo or this or that, and I can't tell from the chart, I might just say one, try to reassure and also say, hey, is there something that I'm missing? Something that didn't make it into the medical record, it didn't make it into your note. Maybe it was the doorway sign and the patient says, when I first started to have the symptoms in this case of my chola docolithiasis, maybe they did have an urgent care visit or a PCP visit for chest pain, maybe that's lingering in the chart and the surgeon really, really, really wants to make sure it's reconciled before 5:30 in the morning on the day of surgery when everybody's gowned up and about ready to go. There are some things that we really do know and we have mounds of data and really cleverly designed studies to say this is wasteful, it does not change management and cost the healthcare system millions of dollars annually. I'm specifically thinking about the study on routine coags in neurosurgery patients. And if you just eliminated universal coags and neurosurgery patients in this country, we're talking like eight to nine figures annually of savings.

[Dr. Paul Nelson Williams]

And I guess, and I know we want to dig into the guidelines, but I would like to hear, and I think you've talked about this on prior episodes too, like this, that that is one instance and I think it is very generous interpretation. I think sometimes I, as the primary care physician I will do perioperative stratification for someone that feels much more algorithmic. So for instance, when I'm doing a urinalysis and point of EKG for someone who's going for cataract surgery, like I guess part of me dies inside but the other part of me. And again, this is by the way, a life changing surgery for patients. So this is not me criticizing ophthalmology colleagues. But I also how what does that conversation look like when it's not even a matter of there's a specific concern. It's just this is what we do and we've always done it this way. So we're not going to change it. Like how do you address that specific specifically? And then we'll dig deep into the guidelines after this. But I'm just curious how you as this being your entire life, how does it, what do those conversations look like and how do you approach them?

[Dr. Avital Oglassar]

Yeah, and that is such a high yield example. I feel like I hear practically weekly from colleagues all over the country that they're having these challenges. And I'll say my number one response to that is often those mandated pre op tests are institutional inertia. It may not be a specific surgeon saying please do this, but it may be a department, it may be a freestanding surgery center that has a policy. It may be someone well intentioned who digs up a letter from 10, 15, 20 years ago and applies it to the wrong surgery. So somebody who's having a cataract extraction, which I can actually agree it can be life saving, can be very safety promoting for someone with vision loss. There's some really cool data coming out for patients with dementia and cataract restoring vision, but maybe we continue anticoagulants and antiplatelets for patients having cataract extractions. Coags are not going to change anything about that. Again, I'm in a position where I can see that pattern recognition and say, oh gosh, I've now heard about three patients who are coming to our eye hospital at Catchlak Northwest and they're coming in with all this paperwork from their pcp, including a type and screen and a chest X ray and ekg. And, and I can go to the A group and say, hey, by the way, we're noticing this really low value testing requirement. Again, be curious, where is this coming from? Can we, can I bring to you all the data, all the evidence that we have saying this is low value and not indicated? And sometimes also for if you have an individual patient whose surgery is about to get canceled and they're about to have to wait another eight to nine months to get it rescheduled, sometimes the best thing to do might be just get it done and then continue to have the discussions. The analogy I want to use is antimicrobial stewardship. And yes, giving inappropriate antibiotics to one patient might actually create a slippery slope of antibiotic resistance and whatnot and complications and C Diff and all those lovely, lovely things. But sometimes if you have a patient right in front of you and that surgery is not going to proceed without coags in that moment, a couple hundred bucks to just get this patient into their surgery and then let's tackle the system is patient centered care.

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[Dr. Matthew Frank Watto]

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[Dr. Matthew Frank Watto]

Avi, I'd like to ask before we start talking about the let's pretend we're at the end of the assessment and we're again communicating to the surgeon our final recommendation. What does that sound like when you're communicating? Either yes, this person seems ready for surgery or no this person doesn't. Like, what do you actually write in the chart? Just because I think that's useful and I get asked that question all the time when I'm working with trainees.

[Dr. Avital Oglassar]

Yeah, love that. My preferred charting style is this patient is or is not stable and optimized for this surgery. And then I have a line in my notes at Cash Lac Northwest to say is further testing needed? Yes or no. And is further optimization needed? Yes or no? I split that out. My group at Cash, like Northwest, split that out several years ago because, like, well, you don't need an echo. You don't need a stress. But if we can work on tobacco cessation, that would be lovely. That would be icing on the cake before surgery. If I can get you to increase your activity levels before surgery, you can still proceed as is. But if in the next three weeks, you can walk around the block an extra time a day, that would be icing on the cake. So stable. Not stable. Optimized. Not optimized. I also have started, especially with the patients, just keep getting more and more medically complex. And at the academic center that is cash back northwest, we see a lot of ASA4 and ASA very complex ASA3 patients. So in those, you know, couple standard deviations out, I will say, you know, this patient is risk appropriate for this surgery. Because, Sable, optimized sometimes doesn't give you that sense. Like, they are still high risk. But is this patient risk appropriate, or are we risk prohibitive?

[Dr. Matthew Frank Watto]

Okay. Oh, that's really helpful. Thank you. All right, Wirtz, what should we go to next? Do we need to talk about the cardiac risk now? I guess that's a big ticket item. Yeah.

[Dr. Paul Wirtz]

I've noticed that with a RCRI score, like, an absolute score of zero may spit out a different, like, risk of mace, depending on which online calculator that you use. And I noticed that's caused some confusion. And so how do you approach that discrepancy? Should we just be using the absolute risk? Are those MACE risks useful?

[Dr. Avital Oglassar]

There is a lot of discussion and debate about the recalibration of the rcri, which I think happened shortly before the start of the pandemic. I feel like it's been at least five or six years, but don't cite me on that. And what happened is the model. So this is a great lesson in that any risk calculator you use, you should know. Data in, data out, like, where was derived from, what is it supposed to predict? So the different risk calculators, cardiac risk calculators in the periops setting do predict different things. The RCRI revised cardiac risk index predicts at least a half a dozen, and I can't even rattle them all off my head. Different types of cardiovascular complications, including mi, including, I think, heart failure, like, decompensated heart failure, malignant arrhythmia. The Gupta, which we all affectionately call it the Gupta, is actually officially the MICA predicts easy to remember. Myocardial infarction, cardiac arrest, mica. When you get into the pulmonary risk calculators, there is a whole plethora and they also predict different things. Some predict respiratory failure, some predict pneumonia, some predict any respiratory complications very broadly, which may include transient hypoxia, atelectasis, bronchospasm. So I think that's one thing to remember first, that risk calculators are not a one size fits all model. I think getting comfortable with it, getting comfortable with the ins and outs and the nuances and some have strength and weaknesses is also a really good lesson in general for medicine. But a couple of years ago, the RCRI model online was recalibrated to try to capture the min so myocardial injury after non cardiac surgery. Background prevalence rate that we are seeing from studies like the vision study that was added to the model. But the original derivation model for the RCRI was not designed to capture that. It's not one of the things it predicts. So the model got thrown off. Some of the best guru advice I've heard from it says, start thinking about it like a D dimer. A negative D dimer has very, very good negative predictive value. So an RCRI of 0 is as low as you can get because you're right, like the RCRI makes it very hard to say like, oh, your risk of a cardiac event is predicted to be over or under 1% there. I also have preferentially been using the MICA or the GUPTA for several years now. It's a larger derivation model. It's a contemporary United States surgical cohort. So the RCRI was derived from several thousand patients. The MICA is derived, I think the derivation cohort was a quarter million and the validation cohort was another quarter million. The ACS American College of Surgeons Nescip calculator, which predicts a lot of different things, is a real time, living, breathing NESQIP national database. It was derived from over 1.4 million patients and they are always adding to it. So now there are even geriatric risk modifiers that you can add to it. So I preferentially don't use the RCRI because I like the GUPTA for many reasons. And the new guidelines have also picked up on the recalibration. I think they're very diplomatic and professional with how they call that out. What they say is if you go through the flow sheet now the line in the sand to consider any potential ischemic evaluation. Is Gupta predicting risk more than 1% or an RCRI score? Of more than 1, they took out the percentage from the RCRI.

[Dr. Matthew Frank Watto]

And what about risk modifiers? Because this was something we had a conversation about a little bit offline. Can you talk about other risk modifiers that we should consider? Because these, you know, the scores don't always capture everything.

[Dr. Avital Oglassar]

And I think you said that absolutely beautifully. And that's one of the reasons I'm so glad the new ACC AHA guidelines has a step to pull in risk modifiers in the flow sheet. So the algorithm which we had in 2007 and 2014, which captures a lot but not all of the nuance in the hundred places, hundred plus page documents, but as you go through that new stepwise approach, there's this giant box for risk modifiers. It includes severe valve disease, severe pulmonary hypertension, higher risk, congenital heart disease, prior coronary revascularization, stent or cabg, recent stroke, presence of ICD or pacemaker. What it helps acknowledge is that even for all these fantastic population health derived calculators that we have, there are patients who are going to kind of test out of the model or fall out of the population health model where even if you put them through a validated risk calculator, they have unique risk, unique factors that is going to kind of, they're going to kind of fall off the population health model and that those things need to be accounted for. And frailty, I know we want to talk about frailty, so I will get that word out there now. Frailty is one of the risk modifiers and then I'll just step on my next soapbox for a second. One of the things I love the most about this new guideline is that it is very holistic and very broadly focused and it is not just this is a cardiac condition, this is your cardiac risk. Things like anemia and frailty make an appearance as risk factors for post op poor outcomes. And in addition to all the nuance, there's a lot of real estate now on beyond core ischemic disease and heart failure. But hokum and patients who have received Tavrs and patients with LVADs and patients who've had heart transplants, they all have attention paid to them in this new document, in this new guideline.

[Dr. Matthew Frank Watto]

Paul Williams, any any comments on the risk scores before we maybe dive into frailty? Or is that any anywhere else you want to take this right now?

[Dr. Paul Nelson Williams]

No, is the short answer. I would actually love to hear a little bit more about frailty since we're already on the topic, because I think that was one of the questions I had as I'm reading through the new guideline, I love that it's considered. Again, going back to my point that sometimes it feels like the question is can this person be operated on or not? And is not viewed as a what does their prognosis look like afterwards? And what are we doing with this information? So I guess my broad question for you is how are we assessing for frailty? And then what do we do with the information? Because lots of patients are frail and does that mean, like, what am I to do with this is my eternal question. So I would love to know how you evaluate them. Also how it informs what their trajectory looks like from there on out, because I can't make them not frail most of the time.

[Dr. Avital Oglassar]

And that all really, really valid points in such a great introduction to this. And one of the things I say when I'm teaching about perioperative medicine is why are we predicting? We're not just predicting to get a static statement of risk, a percentage on the chart into the medical setting. We're trying to predict so we can try to prevent. We're trying to predict what a patient is at risk for so that if we proceed with surgery we can be as proactive as possible rather than have to be reactive. Like I'd much rather, as an example, have someone whose volume status in I's and O's is very, very closely monitored. If they have fragile heart failure from post op day zero onward, including instructions on discharge, then it'd be post OP Day 4. The goal was to discharge that day. But there's a rapid response being called for, hypoxia and new oxygen requirement, and they're indeed compensated heart failure. But why are we assessing frailty? Why do we have a new cardiology guideline saying that There's a Class 2 recommendation to screen for frailty? If we're not going to do anything with that, and the answer is we are going to do something with that. It may be cancellation of surgery. It may be cancellation of surgery permanently because the surgery is so risk prohibitive. There's that phrase again, that ultimately the risk benefit is not in favor of proceeding with surgery. Maybe it's a postponement of surgery because there is more and more data coming out that we can reverse or risk mitigate frailty. Maybe there's things that we can do especially to optimize a patient, or we maybe even say, and there are a lot of surgery groups that I work with who use frailty assessments to help triage patients to invasive or less invasive. Classic example is TAVR patients. Frailty is one of the reasons where someone may be risk prohibitive for an open a surgical aortic valve replacement, but they're an excellent candidate for a tavr, which is lower risk. So frailty is a syndrome of decreased physiologic reserve. It is different, but over. You can imagine the Venn diagram here. It is different than comorbidity. So you can have a lot of medical conditions and not be frail. It's different than disability. But you can also have two or all three at the same time in a patient. And the images that we use to what is frailty? What is decreased physiologic reserves or a syndrome of decreased physiologic reserve? This graphic is decades old at this point and like the original citation has been buried. But there's an image of a narrowing precipice where you start off with a very wide like platform and then just gets narrower and narrower and narrower. And if you are not frail, if you have physiologic reserves, you can withstand more physiologic insults. So I remember like from med school, the classic example was a 20 year old, very, very healthy, robust patient who's in hemorrhagic shock is going to look pretty good until they can't maintain their stroke volume. But if you are walking a very, very narrow tightrope, think of like you walk in an exam room and you're like, if I sneeze, this patient's going to break a hip. That's frailty. There are better, better validated tools to measure frailty. But that's my eyeball. That's my doorway test for frailty. So the patient, the 90 year old with dementia who is inpatient for four days with a UTI, has far fewer physiologic reserves than a non frail patient.

[Dr. Matthew Frank Watto]

Yeah, it's kind of like somebody that has some underlying memory issues or dementia. They much easier slide into delirium than somebody who is like defending their thesis or whatever. So it's, I think it's a similar situation. Do you use any of the scores? I know there's the frail score. That one seemed fairly easy to do or that one seemed fairly easy to calculate to me. But do you have a favorite score that you use or is it more really just the eyeball test that you're using or just your gestalt?

[Dr. Avital Oglassar]

I'm glad you asked that. I preferentially use the Edmonton Frail scale, and I've been using that one preferentially for, gosh, almost a decade if not more than a decade at this point. It's very patient centered. All of it, except the clock draw can be done unassisted by the patient or without a clinician in the room asking patient questions like, you don't need a grip strength. It does also involve, I apologize, it does involve the time get up and go. So there's two components where you need some objective data rather than subjective. But I will give patients a sheet or a dry erase board with the questions. There's a lot of psychosocial questions on there too, which often creates a signal that there's something else to pursue, like psychosocial sport or social work or case management with a patient. And then in my group at Cash Slack Northwest, we also pair that with the minicog for cognitive screening. So the clock draw goes into both. For telehealth visits, I have different tools because I have actually not ever attempted to do a time get up and go with someone in their own dwelling. I know ambitious geriatricians who can pull that off, and I know people who can do clock draws and the mini cog over telehealth. I have not been successful in that domain. But I heard Dr. Zara Cooper, who's a surgeon with a focus in geriatric perioperative medicine somewhere in Boston, I forgot which hospital. I heard her speak a couple of years ago and what she said is, there is no one frailty calculator, frailty scoring system that predicts that frail patients do better. They all predict worse outcomes. Pick one, get used to it, get comfortable with it and use it routinely. And I think that's great advice. And that sort of dovetails into what I was saying about the other risk calculators.

[Dr. Matthew Frank Watto]

So when you assess frailty, you do the Edmonton frail scale. You're worried a patient has frailty and they're going, let's apply it to our patient, this 77 year old guy, a lot of comorbidities, and right now we're saying he's frail, but he needs this cholecystectomy recently was hospitalized for cholidocholithiasis. So what might the conversation go like? You know, telling him, okay, I don't think you should go for surgery. Like, how do you have those conversations? Like, if you think it's reversible, you mentioned maybe it could be reversible or if you think it's not reversible, what would that sound like?

[Dr. Paul Nelson Williams]

Yeah.

[Dr. Avital Oglassar]

So for this patient also, I would say, what is life like for you now, both subjectively and then get Some objective data. How different was it before you were admitted with the cholidochthiasis? If this was a nonagenarian who was going to the gym three times a week, still volunteering at a community center. So keeping the body sharp, the brain sharp, and you know, is back feeling at 90% of baseline after their hospitalization, that's going to be a reassuring data point. Or if they say, you know, I really felt like that hospital stay drained me, I haven't gotten back to the gym yet. I'm feeling like I lost a ton of muscle mass. Maybe this is short term and to be able to say like, hey, like I know what you're capable of. What can we do to kind of get you as close back to that best recent baseline before your surgery with nutritional optimization? I'm going to start using the term optimization a lot here. Maybe it's really emphasizing protein intake and high quality sleep and rebuilding strength and stamina through some sort of exercise program, be it through physical therapy or self directed. And I've had plenty of patients where well intentioned. They were told, oh, you know, just, just take it easy. You know, we're going to discharge you, your surgery's going to be in a few weeks. Just go home and take it easy. And it's like, no, I actually don't want you to take it easy. I want you to P yourself because I need to get you back into another physiologically stressful setting. And maybe this is a patient who was also who was frail going into their hospital stay for cholidocolithiasis and they've only gotten more frail. And the data that we have in the best guidance is to think of frailty as multidimensional, multimodal. And there's even discussions of kind of the different phenotypes of frailty. Is it physical frailty? Is it kind of more psychosocial frailty? Surgery is stressful even if you are younger and healthy, like you need support to recover from surgery. So I think that's just a good pause point. In general, what resources can this patient rally to empower them for the smoothest course in the hospital going home. So maybe it's that, you know, go walk around the block. You already walk around the block once a night, do it twice a day between now and surgery. Who's going to help you at home? Maybe if someone really is screening as frail or screening as someone is, you worry that they're high risk for delirium. This is the patient. I will do that. Anticipatory coaching Say I want you to think, I want you to actually do guided imagery. You are going to get out of bed after your surgery either with the nursing staff, with your family. You know, I don't want you to get up and fall. Maybe it's a formal physical therapy assessment in the hospital, but like I need you to be mentally prepared to not just sit in bed after surgery. I will do guided imagery with patients to say, I'm going to teach you the term out of bed to chair like, and enlist their family and say like, you know what, the thing that's going to help you recover from this surgery as smoothly and expediently as possible is early ambulation. This, that, other risk mitigation strategies. So sometimes it's that anticipatory counseling. I said early on in this recording. It's not just is this patient going to get into the hour, not be canceled, it's really thinking through this spectrum.

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[Dr. Matthew Frank Watto]

So if we think there's a prognosis where this could be reversible, then you know, then maybe we, we buy ourselves a little time, we come up with that plan. If it's someone who has been frail and is just continuing to slide down and they want to go for an elective procedure that may, it sounds like it would be reasonable to just tell them we don't think they should go for it, that they could have all these complications. It could worsen their health overall. To go for surgery, is that something that you're ever doing?

[Dr. Avital Oglassar]

It is. And just in the setting that I'm in, it's something that I'm doing not infrequently. And I know you had also asked earlier in the prompt, like, how do you tell a surgeon like, maybe we shouldn't be doing this surgery? For me, it always centers on a statement of I'm concerned about this patient. It has to be patient centered. So if a patient comes to me, I see them for a surgeon, I say, hey, I'm really worried about this patient and their risk of this being a very tough post op course. Again, it's try to make it relational, try to make it a discussion as much as possible. And sometimes you're like, I been pleasantly surprised. Where I've had gyne onc, surgeons say, you know, yes, they have endometrial cancer, but I can bias two to three months with an IUD placement. Everyone thinks malignancy related surgeries are the classic time sensitive. We're not going to delay for anything. But sometimes a surgeon could say, you know what, it's low stage, it's not aggressive, it's, you know, this is the type of disposition dysplasia we are seeing. If you're worried about this patient and something for a month or two months is going to help us lower this patient's risk profile, we have that time is the most important thing I can ever have. Or maybe even the surgeon says, oh wow, you know, the risk benefit that I phrase for them with all the additional things that you have helped me learn about this patient, we need to recalculate that risk benefit, a quick balance and I need to bring them back to my clinic and have another face to face discussion, say like, we need to reframe risk and what is the risk appropriate care for you?

[Dr. Paul Nelson Williams]

Can I ask another one of those cultural questions, Avi, which I guess is sort of what does in terms of the context of doing the risk stratification and sort of the assessment that you do, what does your post operative involvement look like if anything? So for me, you know, especially at the last place that I was at as the primary care doctor doing that, the risk assessment, it would not be unusual for me to visit the person after the surgery and then even call the team and be like, hey, I'm concerned about this because I was there 20,000 years and like knew everybody. So I could just Call and be like, hey, yeah, yeah, you might want it. But for, for someone who is seeing you in your clinic for perioperative stratification and evaluation, is there any kind of point of contact post op or how do you ensure that those sort of the long, longer term recommendations are actually being followed through upon not just filed in the chart under assessments?

[Dr. Avital Oglassar]

And yeah, I appreciate you asking. So I am 100% outpatient at this juncture, so I'm not seeing anyone inpatient post op. But we've also built up relationships with the colleagues who are in the position to deliver that care after surgery. We have a really, really wonderful relationship with our inpatient geriatrics consult service. And very often so if somebody screens as frail or screens as having cognitive dysfunction and feels high risk for delirium, we will route the chart. So again, being proactive versus reactive, like, I'd rather have geriatrics start following along on post op day zero than on post op day five when they've been delirious for three days or in a hypoactive delirium that had a delayed diagnosis. And there are other colleagues we will do that with as well. So Cash Lac Northwest has an addiction inpatient addiction medicine service. So maybe it's also doing a very, very warm handoff to that subspecialty team. Or maybe it's the pain service. Or maybe it's, you know, please make sure physical therapy sees this patient on the weekends.

[Dr. Matthew Frank Watto]

Avi, we had given this guy our patient. He has osa. He uses cpap. And you had mentioned there's some pulmonary risk calculators. When you're seeing people in your outpatient clinic pre op, what are you telling them about osa, how are you handling that? And then I guess if you can comment on like the surgeon here requested PFTs as well. So maybe you can tackle both those.

[Dr. Avital Oglassar]

Sure. I'm going to knock PFTs off the to do list very quickly. And say outside of thoracic surgeries, there's no data to say patients should have PFTs before surgery. I would just say if somebody is undergoing an evaluation for dyspnea of unknown etiology and because of the cardiac evaluation is reassuring. If you would get PFTs in the outpatient's primary care setting, it's probably prudent to get those done before an elective surgery. But outside of a patient having thoracic surgery like a wedge resection or a lung reduction surgery where the thoracic surgeon has already ordered it to determine if the patient meets surgical Criteria. I honestly cannot remember ever ordering PFTs. Maybe once in the last 15 years for someone who had unexplained dyspnea. Sleep apnea though, that is another hot topic. We've had guidance for over. I've been in pre op clinic for almost 15 years, believe it or not. So I'm like over under a decade. Over under 15 years. We've had guidance for that long to say this is a perioperis factor. And in the last decade we've learned so much more about pulmonary hypertension as a giant perioperis factor, especially once it's more advanced, that there are a lot more eyes on sleep apnea. This is one of the things. If I had a magic wand and could and unlimited cash flow and no issues with insurance barriers and appointments. Anyone who had a stop bang that was elevated ideally would be getting some type of sleep study or home sleep study. We just don't have the resources for that in this country. You know, if somebody has a stop bang of seven and they have daytime fatigue and they have afib, you know they have, they should be getting a sleep study. It is very rare just with the health system in this country for me to delay or postpone or cancel a surgery for a sleep study because that's just the reality of the situation. Do I still risk assess so that I can risk, modify and act proactively? And I pull this from the data that says if you have untreated sleep apnea, you may still proceed with surgery in the appropriate setting. So like frailty, maybe it's saying you should not be done at an ambulatory surgery center and get sent home the same day. Maybe you should be done in the hospital setting. Maybe you should be done in the hospital setting with preparation to be admitted overnight for monitoring and observation. So get that. How are we going to risk, modify on the back end of surgery? There are some surgeries where CPAP might also be contraindicated immediately afterwards. I think about patients who have endoscopic, transtenoidal, like pituitary mass resections. Pretty sure their surgeon doesn't want positive pressure blowing up their nasal passages into that fresh surgical bed. I know patients who have a Nissen, they don't want positive pressure and potentially blowing down the esophagus right after the surgery. Sinus surgery. I can't imagine wearing a CPAP machine right after sinus surgery. And I know patients who maybe sometimes have that sinus surgery and that's because they have a septal deviation and their nasal congestion is actually contributing to their sleep apnea physiology. So there are things we can do to risk modify patients and risk mitigate. Patients outside of CPAP sleep with the head of the bed elevated. So if you're like, if you think about the patient who has mild sleep apnea and they don't need cpap, maybe it's sleep on your side, maybe it's sew the tennis ball into the back of your pajamas, maybe it's prop up on a few pillows. So I will counsel patients that as well. You know, I want you to sleep propped upright. I want you to go low and go slow and be very cautious with your opioid dosing before bedtime. So you know, if you're feeling and I'll even say like maybe just take half the dose that you've been doing through the day and do acetaminophen and you know, the lowest dose of your range or half dose of your range of prescribed opioids before bed and I'll counsel them about that.

[Dr. Matthew Frank Watto]

Avi so we have a listener from Patreon who had a question about medications and I want to talk about medications in relation to our patient. But we'll hear this listener question and you can answer.

[Dr. Avital Oglassar]

Hi, my name is Garrett Tessman.

[Dr. Paul Nelson Williams]

I'm calling from rural Wisconsin and my.

[Dr. Avital Oglassar]

Question is about when to stop long acting arbs prior to surgery and if those medications really need to be stopped. It seems a little unusual to stop a patient's blood pressure medicines prior to a procedure where they might cancel their procedure if their blood pressure is too high. And it seems odd that for long acting arbs it may still be in someone's system 24 to 48 hours later to only stop them the day of the surgery. Thanks so much for everything. You do.

[Dr. Paul Nelson Williams]

Have a great day.

[Dr. Avital Oglassar]

Take care. Well, that is one of our other million dollar questions in perioperative medicine. And I think if you're going to find anything that elicits a very, very strong reaction on either side of the discussion, it's arbs and aces and GLB ones and SGLT 2. I'm just shooting my blood pressure up just saying those words out loud because they are, it's not, it's not black or white. It's a very nuanced patient centered discussion which, you know, sometimes makes that medical decision making challenging, especially if you don't have, you don't know who your anesthesiology colleagues are in an institution and you can't haven't been afforded the opportunity to have those institution level discussions about Culture and best practice. And this is really an area where, if anything, it's getting more and more nuanced and complicated. But, but that's gonna be the right thing for patients. And that applies to a lot of the medications we manage. What's the concern? The concern is that the with the ACES and arbs is that they're vasodilatory medications. And with general anesthesia, the risk of blood pressure drops and sustained hypotension under anesthesia is there. So that, you know, do I continue, do I hold these medications? How will it change? Interop management is a really, really important question. The reason this gets even more nuanced and complicated is it's been a long time coming, having really good prospective RCTs. And the way that the earliest studies were designed, you may have had metrics of decreased prolonged hypotension in the or, but did it translate to post op aki, post op cardiac complications, increased lengths of stay, or was it just the anesthesiologist needed to give pressors and more fluids in the or? So again it's what did we study, what did we measure, what did we capture? The more recent studies to come out, there have been several, including the Stop or Not trial that came out in the last year. And I'm forgetting the wonderfully witty name of was it space trial that came out the year before. Honestly, at this juncture, we're at flip a coin. It takes the same. It really is. It takes the same. I told you it was getting more and more nuanced. It takes the same number of patients continuing their meds and holding their meds to have both hypertension and hypotension. And really it needs to be patient centered. One of the studies that I really like to reference came out of University of Nebraska before I'm like over under on the start of the pandemic, before the start of the pandemic. And it kind of looked like the number needed to treat, the number needed to harm by withholding or continuing therapy was the same. And then the risk was hypertension of meds weren't resumed. So I think that's also a really great lesson if you think about how the healthcare system functions on the inpatient setting. I'm sure we've all been in a position where it's 9:15 in the morning and we're starting internal medicine rounds on a patient and we have a discussion. And the morning labs finally came back and the creatinine bumped a little bit and oh my gosh, morning Med pass just happened and they just got their arm or they just got their ACE or they just got their loop diuretic. I always like to say like make it on the post op side of things. Make it an individualized day by day discussion. On the pre op side of things. I'm going to read from the 2024 ACC HA guidelines. They really do like how they discuss it. So for starters, there's a two way recommendation that if a patient is on chronic renin angiotensin aldosterone system inhibitors for chronic systolic heart failure so that afterload reduction perioperative continuation is reasonable. And that's something that I've been doing for a long time too. If you were on 2.5 of lisinopril bid for your EF of 25%, I actually want you to have that hemodynamic support on board. And let's assume that the surgery is risk appropriate for that patient. Maybe someone who's listed for heart transplant needs a biopsy to exclude malignancy to stay listed for transplant. Like they really do need to get the surgery done. The new guidelines now have a Class 2B recommendation and it kind of reads like a double negative. So you got to like twist yourself do like upside down and backwards on this in select patients. And the little star is patients with controlled blood pressure and undergoing elevated risk surgical procedures. Patients on chronic RASI for hypertension omission 24 hours before surgery may be beneficial to limit interop hypotension. Omission might be beneficial. It doesn't say to hold them, it says maybe you want to hold them. And it's like wait, what? But I think this has actually given us a lot of room as well as the like. Is there any line in the sand that says this blood pressure needs to have a surgery canceled? And that's a whole other topic of discussion. But let's say you have someone who has very very well controlled primary hypertension on 10 of lisinopril and they are coming in for a long surgery where the risk of intra op hypotension is real and it's high. So an eight hour scoliosis surgery, those patients are going to be hypotensive and getting fluids and getting blood products. If that patient's baseline is 115 over 60 on their therapy, I'm going to feel very comfortable having them hold it. Their risk of inter op hypotension has met my threshold. If I have someone who is on three or four drugs for antihypertensive therapy and they still are riding at like 150 systolics. And they're having a day surgery with general if they're having carpal tunnel release with local and some anxiolytics, because regional anesthesia options for surgery beyond general anesthesia are really, really, really expanding. So if I know that this patient is going to have deep sedation and local, I'm going to continue their meds. They're not at risk for interop hypotension because they're not getting a lot of vasodilatory drugs as part of the anesthesia cocktail. Maybe someone is having a hour long inguinal hernia repair with general anesthesia. So not a big risk of interoperable hypotension, inherently not a risk of fluid shifts, not a risk of blood loss. And they are on Amlodipine 10 and Hydrochlorothiazide 25 and Losartan 50 or Sartin 25. Let's make it 25. And they're running 150 to 160 on those agents. I might actually continue that patient's ARB because I know what their baseline is. I know what the risk of shooting up afterwards is. Or if somebody maybe runs runs high and they take it at night, I'm going to have them take it the night before. Or if they're running low, I might have them skip the night before. So I look at all the other medications they're on and you know, again, is that quantify and qualify? I said early in the beginning, you can't just say this patient's hypertension. You need to actually learn about that patient's baseline hypertension management and control and make an individualized decision.

[Dr. Matthew Frank Watto]

Okay, so it basically sounds like case by case. If they tend to be on the lower side, you might hold it. If there's someone who's, you're barely controlling their blood pressure at baseline and it's a low risk of hypotension and blood loss, you might continue it. The other question we had pertinent to this was from Nandini Anandu, also from the Patreon asking, I believe.

[Dr. Paul Nelson Williams]

Nandini.

[Dr. Matthew Frank Watto]

Nandini.

[Dr. Paul Nelson Williams]

Nandini.

[Dr. Matthew Frank Watto]

Nandini. Sorry. Okay, I'm learning. So she asks, what about what blood pressure level do you consider acceptable? Because she knows there's no guidelines. She says Drs. Merle and Weitz recommend less than 180 over 110. Those are the console guys. So that sounds like it's probably true if that's what they Recommend. But is there a specific blood pressure cutoff? I think we just in general have pretty little guidance on like what inpatient blood pressure or what perioperative. Let's stick with perioperative. What perioperative blood pressures are reasonable.

[Dr. Avital Oglassar]

Yeah, that's. That is also, I would say perioperative hypertension is one of the things that raises my blood pressure in the pre op clinic. So first I would start by saying again, get more information from your patient. Do they have white coat hypertension? Although as a colleague said to me the other day, avi, you don't ever wear a white coat. Like can I do like insert soft shell jacket brand hypertension? I was like, I'm going to use that from now on. Does this patient routinely run high at office visits? Have you checked their blood pressure appropriately or were they racing in from the waiting room and they didn't sit for long enough? So one make sure you have an accurate number. I always ask about home trends. I look at other vitals, what are our thresholds? And this is where there really is just so much head scratching in the literature. Thankfully the 24 ACC HA guidelines talks about it and what they say is Class 2A recommendation. And by the way, I'm reading this. I am not. I did not memorize this.

[Dr. Matthew Frank Watto]

No one take the credit. Yeah, yeah, you could have. You could have been.

[Dr. Avital Oglassar]

I'm trying to be humble. I've memorized the 101 page document entirely, including where the asterisks are. So class 2 a recommendation in most astrac patients with hypertension plan for elective non cardiac surgery. It is reasonable to continue medical therapy for hypertension. Okay. That's what we just talked about. So if you have hypertension, you should take your antihypertensives going into surgery unless we need to individualize your H and R plan. Got it. Okay. To be or not to be recommendation in patients who have cardiovascular risk factors. So our patient, for example, has known cardiac disease or risk factors for periop complications. Add a history of poorly controlled hypertension and they define that. The guidelines define that it's greater than or equal to 110. Sorry, 180 systolic or greater than or equal to 110 diastolic, which is really high. Deferring surgery may be considered to reduce the risk of complications. And I'm like, wow, they went that generous. And that's where the consult guys have what they have used as well. In the pre op clinic though, I'm sort of straddling the. Is this okay, enough for surgery. Is this where you should be long term for health maintenance? And am I thinking like your primary care or not? I don't necessarily want people as tight if they're not controlled. I don't necessarily want to get them as tightly controlled as I would if I've seen them in the primary care setting because I don't want them to bottom out. I don't want them to have complications from going too low too quickly. I am personally, this is my expert opinion. I am perfectly thrilled to see someone sitting in the 130s, 140s in pre op clinic. And if they say, you know, at home in the morning, I'm 120s, beautiful, fantastic. If they're like 160 in pre op clinic and they say I'm always high at visits, I was running late, the parking lot was a mess, I went to the wrong location and I look at like all their other recent office visits and they're 135 and they're 130 at home. Like, I'm really happy with that. I will document as such. I will include that in my medical decision making. But if someone is, is running 180, 190, 200 recently, and maybe again it's that Ted Lasso, be curious. Maybe they ran out of refills. Maybe you know, something has changed or maybe they just haven't been able to get in for primary care. I like to start having a discussion about adding or up titrating antihypertensives if we are really routinely seeing numbers above 150 to 160 systolic. Because I think that's also best for the patient in the long term. And what I'll also do, unless I have clear data that this is their established trend, I want to say, like, go to the pharmacy, buy a blood pressure cuff if you don't already have one, and get numbers and send me a portal message in, in a week if I have that time, or three days and let me know what your numbers are at home. And most of the time patients are actually absolutely fine at home. They're riding the one teens to 120s to 130s. Maybe they have a lone bump to the 140s or 150s. But if I can really say like you are running consistently less than 150systolic, I'm very happy about that before surgery.

[Dr. Matthew Frank Watto]

Yeah, that's similar to what we do in primary care. Just when we're deciding if we need to escalate medications or not. I don't know. Paul, does that sound pretty much like what you do?

[Dr. Paul Nelson Williams]

Yeah, a million percent. Yeah.

[Dr. Matthew Frank Watto]

Yeah. All right, so our patient is on. I believe our patient is on Tirzepatide as well. But before that, I wanna play you another voicemail from a listener. Cause this is kind of pertinent to this.

[Dr. Avital Oglassar]

All right.

[Dr. Matthew Frank Watto]

Okay. All right.

[Dr. Paul Nelson Williams]

My name is Drake Duckworth out of Kansas City, Missouri. I hope this is close enough to periop kind of management stuff. But can someone scare me away from making my patients all NPO except for meds? This may be more specific to somebody getting into the hospital needing some operation for whatever reason or a heart cast. But I've been making them all NPO accept meds and making my residents do that. And we haven't gotten in trouble yet. But I'd love for somebody to scare me into doing something different. Thank you.

[Dr. Avital Oglassar]

Props for how you phrase that question. I just got to like be present and sit with that. I like that. When you said, I think this is close enough, I thought I was going to say close enough to the Super Bowl. You all know I trademark. All right. Philly, Philly, Philly roots. I have Philly ruts. You all know that. Can you guys promise me to include the link to the really beautiful, phenomenal General Hospital medicine things we do for no reason are article about MPO after midnight in the show notes?

[Dr. Matthew Frank Watto]

Yeah, absolutely. Sure. Well, Paul Wertz, he will. He will promise.

[Dr. Avital Oglassar]

Is that a Lenny Feldman one? Is that a Lenny and Tony one? I forget who wrote that one, but it's such a. The whole series is great and that's a great one.

[Dr. Matthew Frank Watto]

I. I know. Yeah, I know that they have the trademark or at least Lenny does.

[Dr. Avital Oglassar]

Trademarked. Sorry, I violated trademark again during our recording. I haven't said any brand name yet. Oh, NPO after midnight. Talk about institutional inertia and dogma. Some of my talks about this actually have like an image of from the Dogma movie. The guidelines, the guidance from our, even our anesthesiology societies is that patients can have clear liquids until two hours before. Now how you turn that on? Where's the clock? Is that two hours from inducing anesthesia? Is it two hours from check in to the admitting desk before you get to the pacu? Because that's another two hours before you start surgery. That's a whole other question. And because we also want to give patients a safe window. The data has supported in general that gastric emptying to clear liquids is fast enough that the aspiration risk. Because really what we're Trying. What are we trying to prevent? We're trying to prevent aspiration during airway management with deep sedation or anesthesia, most patients are going to be able to digest clear liquids. And we're talking about truly clear liquids.

[Dr. Matthew Frank Watto]

Like you can read newsprint through it.

[Dr. Avital Oglassar]

That's literally what I tell patients. If you can hold it up to the light and read through it. Black coffee counts as a clear liquid.

[Dr. Matthew Frank Watto]

Tea, Paul, that's great. That's great.

[Dr. Avital Oglassar]

White grape juice, apple juice. Some people say stay away from carbonated because of gastric distension. But lemon and lime, so try and stay away from brands are clear. Cranberry juice, like, are clear liquids. But you got like, I, you know, I've heard of patients who, who thought, you know, chicken broth with noodles was like, that's not a clear liquid. Fruit juice with pulp, not a clear liquid. In Portland, Oregon, we have to very specifically say kombucha is not a clear liquid. This episode was brought to you by the mother.

[Dr. Matthew Frank Watto]

Okay, so it sounds like clear liquids. I still work in places and I have never seen a place that's cool with clear liquids up to two hours before. Even though that seems to be what the evidence says. I'm not sure what other people are seeing. But like you said, it's probably institution dependent.

[Dr. Avital Oglassar]

And this is also a great example of necessity being the mother of invention or are finally breaking dogma and inertia. We have finally been able to really make progress in shifting this narrative and discussion since the IV fluid crisis started several months, about five, six months ago at this point. Interesting. So everyone's like, how does climate change affect perioperative medicine? I said, you have no idea. We at Catchlak Northwest and many, many institutions around the country started to liberalize from that strict NPO after midnight to, you know what? Now we are really going to say we need to get comfortable with the uncertainty of saying, yeah, clear liquids and hope the patients, you know, follow directions accurately. And the other things I was hearing was like, well, you know, maybe their last case of the afternoon and even if they wake up at five in the morning and have a light breakfast, that somebody's going to get canceled and they're going to get bumped up and we won't be able to start the case till three in the afternoon. Like that never happens. But we have liberalized fluid after midnight instructions for patients so that they come in more hydrated. And there are also a lot of surgery protocols. So the ERAs protocol, we're not talking about the residency match and we're not talking about Taylor Swift's ERAS tour, which I constantly called ERAS tour. The ERAS protocol is enhanced recovery after surgery. It's trademarked. Started in Britain over a decade ago, but looked at ways to basically fast track patients recoveries. We know that hydrated patients and patients who have access to carbohydrates do better with surgery. And there are a lot of surgery protocols that with institutional agreements and buy in and support, we're having patients come in npo. Except for clears, there are protocols. So like Cashel Act Northwest, like hepatobiliary program. If you're coming in for a Whipple, you may actually be asked to chug a sports drink with a couple teaspoon tablespoons of sugar in it right before your surgery. And then with the IV fluid crisis, it was like, wait, we have institutional memory with patients not being strict NPO and having better outcomes. So it's actually exciting. Like there was this crisis and we all went, you know what, let's finally lean into this data that we are all nervous to really put into action.

[Dr. Matthew Frank Watto]

And with tirzepatide, with semaglutide, the GLP1 agonist, where a lot of people are on them for diabetes or obesity, now they slow gastric emptying. And I know that some societies, I think the anesthesia guidelines say omit the dose the week before your surgery. And in some cases maybe they're doing like gastric ultrasound to see if there's retained contents.

[Dr. Avital Oglassar]

Yeah.

[Dr. Matthew Frank Watto]

So is that about where we're at right now? Like, we're not exactly sure, but we're sort of telling people, hold it for a week, knowing that it's still in their system and how are we doing that?

[Dr. Avital Oglassar]

Yeah, so that is. And then one of these things that has probably given me more gray hairs in the last year than many other things in perioperative medicine. But the hypothetical concern is these are meds that can dramatically delay gastric emptying. What is the aspiration risk? And there are studies looking at measured gastric contents with point of care ultrasounds. But is that a surrogate marker? How strong is that surrogate marker? Are there studies that have actually looked at actual aspiration events? So that's what we're still trying to piece together. And the newest version of society guidance basically says like, you need to ask patients like a dozen different questions, including like reflux symptoms and symptoms of delayed gastric emptying and other factors. And are you on a maintenance dose? Are you on the induction phase? Have you had a recent dose change? Like there's so many variables that a lot of folks are just still saying like I'm going to hold it or not. And it's one of the things that we may have, there may be more data that comes out between us recording this and this going to air like things are moving so quickly.

[Dr. Matthew Frank Watto]

Okay, well I mean that's the best we can do for now. SGLT2 inhibitors, they're saying to hold those three days prior to surgery and that's because of risk of metabolic acidosis. You glycemic dka I guess they're concerned about.

[Dr. Avital Oglassar]

Yeah, and that has gotten, that's a fascinating area. Like just real quick, the history of that evolution of knowledge is fascinating. We had data for euglycemic DKA attributable to the SGLT2 inhibitors in the periop setting within a year of them being approved by the FDA in 2016. And it showed up first in the bariatric surgery patient population. So patients who have very significant changes in carb intake and fluid status post op. And then it is expanded to like we have data for other surgical populations. The challenge now is the expansion of indications to patients with heart failure or CKD without diabetes. There are a small number of case reports that have been published in the peer reviewed literature that patients without diabetes, and I think maybe even without glucose intolerance or pre diabetes but on these medications for heart failure do have the potential to enter a euglycemic DKA state. Small number. In my discussions with heart failure cardiologists and other cardiology colleagues, they are genuinely concerned about patients risk of decompensated heart failure if they're holding a medication that is functionally acting as a diuretic. I mean it is, it's a diuretic, it causes an osmotic diuresis and has other cardiovascular benefits. That's why these meds are so exciting. So we are in. If you have heart failure with or without diabetes, my expert advice is to individualize those discussions. Again, it's ask the patient enough information to make individualized decisions. So if someone has very, very fragile heart failure and they have a history of frequent exacerbations and their weight kind of, you know, they, their weight oscillates, they always kind of feel like they're running a little bit above their dry weight, they're on a high dose loop diuretic, they do, you know, their A1C is 5. I am much more inclined to engage in shared decision making that says we are continuing this medication until the morning of surgery itself. If someone has well controlled diabetes and their A1C is 6.36 and their heart failure is really, really well controlled. And they are on a PRN low dose loop diuretic that they end up taking only maybe once or twice a month. I have a much different threshold to say, you know what, I feel very comfortable holding your SGLT2 for three days and, you know, monitor your weights, monitor your symptoms. If you need to reach for that PRN loop diuretic in that three day hold window, that's what it's there for.

[Dr. Matthew Frank Watto]

All right, well, we have still more to get to, so what's the next part of the case?

[Dr. Paul Wirtz]

Yeah, so let's switch it a little bit to inpatient. So you're covering inpatient call over the weekend. The patient now presents to the hospital with acute onset right upper quadrant pain, fever and imaging findings consistent with acute calculus cholecystitis. The surgery team consults you for perioperative recommendations. So now kind of swinging into many of the new updates. The 2024 ACC HA perioperative guidelines focused on cardiac biomarker testing in certain patients, those at elevated risk. They have a 2A recommendation for pro BNP, it looks like, and then a 2B for troponin and then the updated role of stress testing. So can you speak on this? Like, should we just be getting, you know, troponins on everybody before surgery or how do we, how do we use these?

[Dr. Paul Nelson Williams]

Also, I'm frankly shocked we're just not letting the gallbladder cool off a little bit before we actually go to surgery. So this is an exciting case all the way around.

[Dr. Avital Oglassar]

I'm not touching that part of the case. Yeah, biomarkers. This is one of the things that we were all betting on showing up in the guidelines and with good reasons because there was so much data that emerged or was published and explored since 2014. They are crux a big part of the Canadian perioperative guidelines. A lot of the research has come out of Canada as well. This is one of those things that it really, really, really at this in late winter 2025. I think in large part depends on your institutional preparedness to respond to post op troponin elevations. And I always say that with a pit in my stomach because we like, we should be doing the best thing for patients all the time, no matter what. But I think before anyone implements a routine post op, and I know you asked about pre op, but post op troponin surveillance, I'd say make it a conversation with your cardiology Colleagues, especially those who may be asked to consult on post op troponin elevations. But getting back to the pre op, again, we're trying to predict so we can try to prevent one of the predictions. One of the best cases to say check a pre op high sensitivity troponin before surgery is that if you know that you're going to be checking or you're going to have a very low threshold to check post op troponins, especially with these high sensitivity ones, having a pre op baseline can be very, very helpful to determine is this just a chronic troponin elevation? Maybe this person has chronic diastolic heart failure and they have end stage renal disease on dialysis and they always have a little bit of myocardial stretch and impaired troponin clearance. I'm using the C word in a renal sense, not a pre op sense. Call myself there. And having a pre op baseline can be very, very helpful. At the pre op clinic at Cash Black Northwest, based on my expert opinion, I don't know that I've ever checked a pre op troponin in a resting asymptomatic patient to guide post op or to determine if they should get any ischemic testing before surgery. Because I just, I don't feel like I have a very good mechanism on what to do if in an asymptomatic risk appropriate patient that high sensitivity troponin comes back with an isolated high. What am I going to do for them before surgery? Like I am still working through that challenge myself and it's A2B recommendation for troponins, but it's A2A recommendation for BNP or NT Pro BNP. I actually like having the NT pro BNP or the BNP in my back pocket in the pre op setting. And I've had that sense for years. Not quite how the guidelines currently introduce it, but as one of the tools in my tool belt as an internal medicine physician to engage in clinical reasoning about a patient and their baseline and their baseline symptomatology and sometimes saying like, oh, you know, like when you were admitted, you know, so let's say this patient came in and they're septic with their acute cholecysitis because of their symptoms. They got a chest and they got a ct and in the lung cuts of, you know, the upper cuffs of this abdominal ct, you see bilateral pleural effusions. I don't know if that's from sepsis. I don't know if that's from third spacing Maybe they do have heart failure. So as I'm prepping to see patients, I will look for those context clues and say, hey, if I got a BNP or an NT pro BNP on this patient, what am I going to do if it comes back normal, elevated or in that kind of like indeterminate range? If someone has had one done for any reason, I will certainly like, oh, hey, by the way, you went to your primary care for like the non specific edema edema or non specific dyspnea evaluation and you had a stone cold normal BNP as part of that evaluation and it was really felt like it was attributed to like uramlovapine. I'm still five months after the guidelines have been updated. I'm still trying to build the muscle memory of what does it look like to use the BNP as the step between, hey, this patient is at elevated risk of cardiac complications of mace. Should I get a stress test? Because that's what the flow sheet is now showing. It is an intermediary step between excellent functional capacity risk less than 1% or RCRI less than 1 and do they need ischemic testing and do I have enough other things to say they should be getting ischemic testing? Maybe they've already had a stress test in the last year. I'm not going to repeat it. So the BNP is not going to change my management. So that's a very long convoluted way of saying I'm still scratching my head about the biomarkers and I think a lot of people are as well.

[Dr. Matthew Frank Watto]

Yeah, Paul.

[Dr. Paul Nelson Williams]

But no thank you. That's all exactly right. Yeah, that was, yeah. Because I mean the Williams role of never checking in outpatient troponin remains intact. Like I just don't know, you know, it's, I don't want to be the one getting the phone call at three in the morning that someone's troponin is elevated. I just don't know what to do with the information. And the same with the pro BNP and someone who's asymptomatic. I will say I don't know in practicality, I wonder how often you're going to be checking that in someone who has no cardiac history like that, that. So like, I don't know, like I just, I'm still sort of scratching my head in terms of what to do with it because even in the non surgical context sometimes I'll see cards. We'll check a pro BNP on a patient with a history of whatever, but they feel Fine. And it comes back elevated. The patient calls me like, do I have heart failure now? I'm like, I don't know. So I appreciate that they have prognostic value. I just, I still, I'm not entirely sure how to apply them in the pre op setting, but I. Yeah, yeah, yeah.

[Dr. Avital Oglassar]

I use it in that diagnostic uncertainty range. You know, I talked to, you know, even with my very focused H and P, if I'm like, I am just not sure if these, your dyspnea, your edema, your. I can't see your jvp. Well, I will, I will check it.

[Dr. Matthew Frank Watto]

So it's kind of like the flow sheet for people to look at. I mean you really. It has a lot. It's a pretty complicated flow sheet. It's figure one.

[Dr. Avital Oglassar]

There's a lot there.

[Dr. Matthew Frank Watto]

Stepwise approach to perioperative cardiac risk assessment. And that's in the ACC guidelines. And like we were saying, this is sort of if, like if the patient's low risk, you know, you wouldn't be doing this. This is more for your intermediate risk and you're just trying to get a better feel for things. This can sort of further help you modify your risk decision. But I knew it was in, I think the Canadian guidelines, like 2017. It was in there. Yeah.

[Dr. Avital Oglassar]

2016 or 2017, I think.

[Dr. Matthew Frank Watto]

And Paul, we had reviewed that, I think we had talked about it a little bit last time and it was not in the US being done in the US at all. So I think it's gonna take a while for people to get a feel for how to use these. I guess the big thing, my big concern, and you alluded to this ordering the post op troponin is like, if you don't have a pre op to compare it to, that to me just seems like you're gonna be like, if it comes back at like 70 or something, which is like mildly elevated, you're like, okay, is this their bas or is this like an acute elevation? And then now you're in the territory of, is this mens myocardial injury after non cardiac surgery? Yeah, so we've talked about this before. This MENS is a predictor of increased just cardiovascular risk, whether if the person's not symptomatic even, you know, you just have this just asymptomatic elevated troponin. But tell us about a little bit about MENS and what people are saying about it, why it's important and where you think it's going, I guess. Or where are we going with this?

[Dr. Avital Oglassar]

Yeah, yeah. Yeah. So I think you set me up really, really well to dive into this conversation. So it is some, it is a marker of some type of cardiac injury or insult, you know, insult to your myocardial cells. Your myocardium was insulted.

[Dr. Matthew Frank Watto]

Someone said the C word.

[Dr. Avital Oglassar]

Oh my God. Can I quote you on that one? I'm giving a pre op lecture at ACP in two months. It is a marker, it is a biomarker of some type of physiologic stress on your myocardium without an alternative explanation. If you were septic and if this patient with acute cholecysitis, let's say they get in there, it's gangrenous, it's perforated, and this guy is like septic and hemodynamically unstable in the. Or, you know, maybe there's an alternative explanation. Or if you have a massive PE and there's another indication for, you know, right heart strain, troponin elevation. But as an indicator of strain on the myocardium, it is, it is a very legitimate eye opening risk factor for worse post OP outcomes at 30, 90, and I think even out to a year. I think when we first started to gain recognition that this was a thing about a decade ago from the vision studies and that group of researchers out of Canada, I think there are a lot of people said, oh, it must be a type 2 event. These are patients who are not going to have obstructive coronary disease. Maybe it's microvascular dysfunction or it's some stress in the myocardial cells. And as we gained more and more experience with it, drilling down into what we are seeing in patients, the data is actually really, really eye opening. A lot of patients do have obstructive lesions or they have advanced underlying coronary disease. And I forget off the top of my head which study it is, but there is a study that came out at least eight or 10, 10 years ago that said of patients who develop men's, the percentage of them who are not on guidelines, directed therapy or have an opportunity for risk reduction counseling is embarrassingly low. Like patients were not getting tobacco cessation counseling, patients were not getting put on statins. I think this one study maybe also looked at aces and arbs. But other, like if you have coronary disease, best practice would say you should be on this should be part of your care package. So for me it is, when I see it in a patient, it is a teachable moment, it's a reachable moment. Does the primary care also get the information about it. It's the same thing for post op afib. Did the primary care get the warm handoff that this happened to this patient and they need to be able to have appropriate outpatient follow up? Maybe it is a stress test afterwards, maybe it is referral to cardiology, maybe it's the coronary cta. Because we're doing different types of population primary care type interventions for atherosclerotic heart disease. The managed trial is the only randomized prospective trial to look at a treatment for men's that has been done yet. And it did show that dabigatran improved outcomes. But we're not seeing a lot of patients on post op being initiated on dabigatran post op. There are caveats and there's a word of caution with the study. I want to give all the kudos to the researchers because this is a really big question. They are the leaders in this field and they were the first to do an RCT on it. The way it was powered and the way that the composite outcome was developed, I think there was a, or like a protocol change into the data collection. It was statistically significant for the primary composite outcome, which included arterial and venous thromboembolic events. And it was not statistically significant if you looked at just recurrent MI alone, if I'm recalling it correctly. So there was a lot of saying like, yeah, it reached statistical significance, but you prevented VT elite because you prescribed a bigotryn for patients. We need more research. But if I see that there's a. Somebody has had men's, I absolutely want to make sure they have the opportunity for appropriate care outside of the post op setting.

[Dr. Matthew Frank Watto]

Yeah. And in Figure 6, in the guideline evaluation of abnormal troponin obtained for perioperative surveillance. If. If you get all the way down and they don't have a stemi, they don't have symptoms or like EKG changes that would make you think it's an nstemi, then you're kind of down this MENS pathway. And like you said, if you don't find a PE or sepsis or something else that you think caused it, then, you know, you're thinking, okay, this is probably ischemic MENS and this person should be treated and they give that. I think it's a. Is it a 2A or a 2B? I can't.

[Dr. Avital Oglassar]

That's 2B.

[Dr. Matthew Frank Watto]

I think 2B to, you know, outpatient follow up and they can be started on therapy. I almost think that's one of those things. If you're the internist, seeing them as an inpatient, I think it would be reasonable to start them on a statin before they go. Just not fingers crossed that the primary care is gonna, that could be missed there. And I think it's benign enough to start someone on a statin medication.

[Dr. Avital Oglassar]

I think that's prudent.

[Dr. Matthew Frank Watto]

Yeah.

[Dr. Avital Oglassar]

And maybe you're gonna set tighter double product controls and maybe you really are gonna lean into the tobacco association and the A1C, the Diabetes and optimization. And maybe you will say, you know, it's a little too soon after your surgery to start an antiplatelet therapy, but, you know, Right. You should be having a conversation about aspirin for secondary prevention as opposed to primary prevention once you've recovered from surgery.

[Dr. Matthew Frank Watto]

Send it. Yeah, send them to America's PCP, Dr. Paul Williams, and he will take care of them from there.

[Dr. Avital Oglassar]

And I'll say the analogies to post op afib, transient afib. We have more and more data every year that post op afib is associated with chronic long term afib, paroxysmal afib, as well as stroke risk. So even if someone has a brief run of afib in the hospital post op, that has to be communicated. Even if you're not sure if you should be initiating a DOAC or other stroke prevention, it has to be communicated to the patient and their outpatient care team.

[Dr. Matthew Frank Watto]

Yeah. So as you were saying this, and we've talked about this on the show before, just post op afib, we used to give people a free pass post op or if they were really sick in the ICU and they had afib, we used to say, oh, that was just transient and they don't need to be treated. But now we sort of essentially treat them based on their risk factors. You know, Chad's Vask, if they have a high enough score, you would rate control, rhythm control, anticoagulation. I think the guidelines essentially support that now. But is there anything else you want to say about post op? A fib?

[Dr. Avital Oglassar]

Not so much. I think we've covered what there is to be said about post ophib. The one thing I'll also add is there were some lovely studies. There were several studies that came out in the last year that looked at like, what does it mean to like, appropriately surveil or appropriately manage someone with lone post op afib or isolated post op afib. There's one study, I forget where it was published, that said, I think it was like the length of ambulatory monitoring for recurrence of post OP needs to be longer than like the two weeks you might do in the outpatient setting. So just like, you know, you're right, it's not a free pass. And if you have afib, maybe this person should really, really have a very, you know, Is it a 30 day monitor? We are gaining technological advances that meet patients where they are every year, including certain wearable devices that are FDA approved for detection of afib. So honestly, if I had a patient who had a run of AFIB and converted to sinus rhythm post op, it's an elevated bleeding wrist surgery. So I don't want to start a DOAC before they're discharged. Their heart rate, their blood pressure is great. I'm sending them back out, including to their primary care. And I even set them up for a two week monitor on discharge and the monitor shows no afib. If they say, hey doc, I have this wearable device, should I turn on the AFIB detection setting? I would say absolutely, because it might take us another month or two months to capture that you're in afib. And if your wearable device is signaling this, get, get appropriate medical care. The, the newest guidelines also talk about, you know, if a patient is rate controlled before surgery, what do you do? If they're not rate controlled, it's treat the underlying triggers or potential triggers. And I actually really like. It's a Class 1 recommendation. In patients with new onset AFIB identified in the setting of non cardiac surgery outpatient follow up for thromboembolic wrist stratification modification and AFIB surveillance is recommended given high risk of AFIB recurrence. That's just like a mic drop statement. It's basically as you summarize, it doesn't go away. It's something to know about, it's something that can cause harm to patients down the line and we can't forget about it.

[Dr. Paul Nelson Williams]

And this is a change from when Matt and I started practicing like it was, you know, you used to just forgive post op AFIB all the time. Like, yeah, they had afib, but I mean they just had surgery. What are you going to expect? Everyone gets AFIB after surgery, which of course is patently untrue. So this has been a market evolution.

[Dr. Matthew Frank Watto]

Yeah. And I guess the one last AFIB question Nandini also asked about this was like incidental nuanced AFIB in the pre op setting. Does that mean we have to stop, not do surgery?

[Dr. Avital Oglassar]

Oh, that is another one of the million dollar questions and one that definitely leads me and my colleagues to lose some sleep at night and I'm going to go back to the quantify and qualify. Get that really nuanced cardiopulmonary review of systems from a patient. Are they having any symptoms or not? Are they having any sensations of at least tachycardia and rapid rvr or are they really running rate controlled? Maybe they say on their wearable device like my heart rate's always in the 60s and 70s and they're asymptomatic, their functional capacity is great and there's a lot of there's not great guidance like does this patient need their surgery postponed or canceled? I don't think of AFIB as a herald for ischemic heart disease. So I do not go AFIB distress test in the pre op setting unless there's something else that says, oh, like you should, like you have chest pain when your heart rate's above 100. Am I going to throw add on a TSH? I've gotten appropriately evidence based high value resource utilization. I've gotten a basic metabolic and a CBC on a patient. If I see someone with incidental or lone AFIB in the pre op setting, I'm going to initiate some diagnostic evaluation. I'm going to initiate an attempt to start working through a differential diagnosis. So maybe I've already collected their BMP and CBC because that's appropriate for the surgery. If I can add on a tsh, I'm going to add on a tsh. This may be a patient I'm already calculating a stop bang score on, but I should relate to their primary care. Like hey, they have new onset afib, they're rate controlled, they're asymptomatic, it's a time sensitive surgery. Let's proceed. But please make sure that they can get in to see you as soon as possible to talk about an evaluation. If someone has low functional capacity or cardiopulmonary symptoms, I'm going to start actively thinking like do I want to get an echo to look for structural heart disease rather than ischemic heart disease? Will that change management before surgery? If someone has lone afib, their heart rate is 60 beats per minute and it's again that carpal tunnel release with local and some sedation or a cataract extraction with just less topical. And they're not even going to take an anxiolytic. I'm much more comfortable with them proceeding in a risk appropriate way as opposed to if this is a patient who's coming in for that 8 hour scoliosis surgery where they're going to be hemodynamically unstable assumed in the case. And anticoagulation management is going to get even more complicated with that giant surgical bed. So again, it's, it's, it's the patient, it's the company it keeps, it's the surgery they're scheduled for.

[Dr. Matthew Frank Watto]

And the new guidelines also say like don't start a beta blocker like the day of surgery or the day before surgery. So if they are going to need rate control, then that's going to, you're going to need like a week or two delay at least. Probably. Right. To control them safely and make sure they're not going to have an issue there.

[Dr. Avital Oglassar]

And that's longstanding banda blocker guidance. I cannot remember the last time I've initiated beta blocker therapy with less than a week to surgery.

[Dr. Matthew Frank Watto]

Yeah. Okay. Well, we've covered so much, we have to get take home points at this time. Thank you for all your time. You have multiple kids and dogs needing your attention right now, so we have to let you get back to your family. Probably a husband too, somewhere around there, I'm sure.

[Dr. Avital Oglassar]

So, yeah, I have, I have doubled the number of dogs to two since the last time I appeared on the show.

[Dr. Matthew Frank Watto]

So.

[Dr. Avital Oglassar]

And they are, they are literally zooming right now. And if you hear any background noise, it's my two labradoodles. But thank you. Yeah, so take home. I know we started off earlier on. We talked about how holistic and thoughtful and really broad focused the new guidelines are. And again, I really do appreciate how they leaned into things that things that are not just part of the cardiovascular system, like frailty and anemia is on there as well. And just to zoom out even further, there is so much attention on cardiac stuff in the pre op setting. We spent most of this episode alone talking about different cardiac conditions. It's just the tip of the iceberg in periop. And this is one of the reasons I love, I really do love practicing this niche, interdisciplinary field as an internal medicine trained, board certified practicing physician. So many times you hear, you get the question, is this patient. I'm doing air quotes cleared for surgery. That is code word for does this patient have cardiac clearance in air quotes. And that's code word for does this patient need a stress test. We have so much data and we have old data that pulmonary complications are more common and more costly than cardiac complications. And that is even data before we started to really start capturing the onus on pulmonary hypertension and obesity hypoventilation in the post op setting. So that data I'm sure if we reran it. The cardiac stuff is sometimes the lowest concern for my When I have concerns about a patient being risk prohibitive for a surgery I mentioned frailty is often a big reason to say a patient is risk prohibitive for surgery or not risk appropriate yet. But I literally think through every organ system on a patient any given day and I want those who are not in dedicated pre op clinics to feel empowered to do that as well. So being able to slow down, say oh, there's cirrhosis, maybe they're driving periop risk factor. You know, that child's b approaching child cirrhosis. Maybe that's why they should not be thinking about this surgery. How can we measure this, calculate a risk, have a patient centered discussion? Maybe it's not risk prohibitive, but it needs very, very nuanced planning, interdisciplinary planning. So that patient with von Willebrand's disease, that patients with sickle cell anemia, that patient with hemophilia, how are we going to meet their individual care needs? We haven't even scratched the surface of neuropsychiatric conditions. You know, how do you support a patient with severe PTSD through the periops setting? How do you support patients who are neurodivergent and maybe very, very uncomfortable and unfamiliar surroundings in the periops setting? How are you supporting patients on mat or an addiction recovery through the perioperative setting? There is so much to make space for, to hold space for in a patient centered way and to be able to look a patient in the eye and they're like wow. Like wow. We really did fill the fill the hour appointment and say like we gotcha. Like we have again, we have quantified and qualified. I don't know to say that to a patient, but like knowledge is empowering and knowing what I need to learn about you, I guarantee you is going to help on the day of surgery. It's going to help in the operating room, it's going to help outside the operating room.

[Dr. Matthew Frank Watto]

Well, clearly we have more perioperative episodes that we have to do in the future. Thank you so much for all your time.

[Dr. Avital Oglassar]

Thank you for having me back.

[Dr. Matthew Frank Watto]

You're welcome. All right.

[Dr. Paul Nelson Williams]

This has been another episode of the Curbsiders bringing you a little knowledge food for your brain hole.

[Dr. Avital Oglassar]

Yummy.

[Dr. Paul Nelson Williams]

Still hungry for more. Join our Patreon and get all of our episodes ad free plus twice monthly bonus episodes at patreon.com curbsiders you can find our show notes at the curbsiders.com and sign up for our mailing list to get our weekly show notes in your inbox. This includes our Curbsiders Digest, which recaps the latest practice changing articles, guidelines and news in internal medicine.

[Dr. Matthew Frank Watto]

And we're committed to high value practice changing knowledge. And we want your feedback. So email us@askcurbsiders gmail.com a reminder that this and most episodes are available for CME credit for all all health professionals through VCU [e-mail] A special thanks to our writer and producer for this episode, Dr. Paul Wertz, and to our whole Curbsiders team. Our technical production is done by Podpaste. Elizabeth Proto does our social media. Jen Watto runs our Patreon. Chris the Chumanchu moderates our Discord. Stuart Brigham composed our theme music. And with all that, until next time, I've been Dr. Matthew Frank Watto.

[Dr. Paul Wirtz]

I have a Dr. Paul Wirtz and.

[Dr. Paul Nelson Williams]

As always, remain Paul NelsonWilliams. Thank you and goodbye.