perioperative medicine (easy)

metabolic equivalents (METs)

• Excellent (>10 METs): Strenuous sports (swimming, singles tennis, basketball).

• Good (7–10 METs): Jogging, climbing stairs quickly, heavy yard work.

• Moderate (4–6 METs): Walking up a hill, light housework, golfing.

• Poor (<4 METs): Eating, dressing, slow walking indoors.

Unable to perform basic activities: Indicates very high risk.

**** 4 = ok for surgery ******

Functional status is a strong predictor of perioperative cardiac risk. It's typically estimated via

• Unstable coronary syndromes (recent MI, unstable angina).

• Decompensated heart failure.

• Significant arrhythmias (high-grade AV block, symptomatic ventricular arrhythmias).

• Severe valvular disease (aortic stenosis, mitral stenosis).

BAD HEART = BAD OUTCOMES

cardiac high risks to surgery

METs >4, proceed without further testing

Poor or unknown functional capacity + ≥1 clinical risk factor: Consider noninvasive testing if results will change management.

cardiac testing required pre intermediate/high risk surgery (vascular, intra-abdominal, intrathoracic, orthopedic, prostate)

Continue if already prescribed (abrupt withdrawal ↑ risk).

should I stop Beta blockers pre-operatively/

Continue to avoid rebound ischemia.

should I stop CCBs and nitrates before surgery?

Hold ACE inhibitors/ARBs morning of surgery

(risk of intra-op hypotension; restart post-op if stable).

hypertension med to hold morning of surgery

Give reduced basal dose; hold short-acting morning of surgery.

should I take my insulin before surgery?

Often continued if CAD/stent; stop if bleeding risk outweighs benefit.

should I take my aspirin before surgery?

Hold 5-7 days pre-op (except recent stent).

should I stop Clopidogrel/prasugrel/ticagrelor prior to surery?

Stop 5-7 days pre-op (bleeding risk

should I stop NSAIDs before surgery?

temporary use of short-acting anticoagulant (usually LMWH or IV heparin) when stopping warfarin.

define bridging therapy

high thromboemoblic risk

Mechanical mitral valve (or older caged-ball/tilting-disk valves).

Mechanical aortic valve + risk factors (AFib, prior stroke, low EF, hypercoagulable).

Atrial fibrillation with CHA₂DS₂-VASc ≥7 or stroke/TIA within 3 months.

Recent (within 3 months) VTE.

Severe thrombophilia (protein C/S deficiency, antiphospholipid syndrome).

indications for bridging therapy (temporary use of short-acting anticoagulant (usually LMWH or IV heparin) when stopping warfarin.)

Mechanical mitral valve.

Recent (<3 mo) stroke/TIA/VTE.

AFib with CHA₂DS₂-VASc ≥7.

Severe thrombophilia.

high risks for thromboemoblism

Bileaflet mechanical aortic valve + risk factors.

AFib with CHA₂DS₂-VASc 5-6.

VTE within past 3-12 months.

Non-severe thrombophilia.

moderate risk of thromboembolism

duplex ultrasosunnd

imaging indicated for suspected DVT

Anticoagulation: Heparin → warfarin or DOAC (if not contraindicated).

IVC filter: If anticoagulation contraindicated.

Duration: At least 3 months; longer if unprovoked or ongoing risk factor.

treatment of DVT