Risk Stratification Discussion Paper
Risk stratification plays a crucial role in both predicting clinical risks and conducting comparative audits. Numerous tools for risk stratification are accessible for application in significant noncardiac surgical procedures. Factors such as inadequate physical fitness, malnutrition, sarcopenia, obesity, anxiety, depression, and detrimental lifestyle choices, including smoking, are acknowledged as critical patient risk factors that can lead to unfavourable postoperative results (Carli et al., 2021)Risk Stratification Discussion Paper. However, these factors are frequently overlooked in standard preoperative assessments and are rarely modified.
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The tools for risk stratification may encompass commercially available calculators, laboratory evaluations, or screening instruments. The surgical team can determine the necessity for preoperative optimization of modifiable risks by utilizing risk stratification (Sherrer et al., 2022)Risk Stratification Discussion Paper. The goal of optimization is to enhance clinical, hospital, and patient-cantered outcomes throughout all stages of perioperative care. Preoperative optimization must be approached as a collaborative, multidisciplinary initiative that aligns the patient’s needs and values with the urgency and timing of the surgical intervention. This discussion post discusses three patients and stratifies their risks in the preoperative setting.
Summary of the Patient Cases
In evaluating the preoperative risk for three distinct patients, a range of risk levels is influenced by their individual medical histories and the scheduled surgeries. The first patient is a 60-year-old woman who has no significant cardiac history apart from a newly detected heart murmur. An echocardiogram reveals an ejection fraction of 60% alongside severe aortic stenosis. She is scheduled to undergo total knee replacement surgery. Patient 2 is a 25-year-old man with no prior cardiac, medical, or surgical issues.
He maintains an active lifestyle, playing basketball for over an hour three times a week, and reports no symptoms during physical activity. He is set to have an emergency cholecystectomy. Patient 3 is a 75-year-old woman with a history of coronary artery disease, having undergone previous CABG and PCI procedures, as well as dealing with hypertension and hyperlipidaemia. Her last echocardiogram indicated an ejection fraction of 55-60% without any wall motion abnormalities. She does not experience any current angina or exertional symptoms, and her planned surgery is a hip replacement. However, her functional status is challenging to evaluate due to hip pain that limits her mobility.
Risk Stratifications for the Three Patients
In a preoperative setting, various risk assessment tools, such as the ACC/AHA guidelines, RCRI, and DASI, can be used to evaluate patients’ risk levels (Yao et al., 2021). Patient 1, a 60-year-old woman diagnosed with severe aortic stenosis, is considered at high risk for complications during non-cardiac surgeries such as a total knee replacement. This is due to the increased likelihood of serious cardiac events associated with severe aortic stenosis, despite her preserved ejection fraction of 60%. According to ACC/AHA guidelines, patients with severe aortic stenosis undergoing non-cardiac surgeries are deemed high risk due to the significant potential for cardiovascular complications during the perioperative phase (Johnson et al., 2024)Risk Stratification Discussion Paper. Therefore, this patient’s perioperative risk can be classified as high.
Patient 2 is a 25-year-old male with an unremarkable medical history. His risk level is classified as low due to his youth, active lifestyle, and absence of any prior cardiac, medical, or surgical issues. Although he requires an urgent cholecystectomy, the procedure does not involve significant risk factors for complications during the perioperative period. His excellent functional status is demonstrated by his ability to engage in basketball for over an hour three times a week. While emergency surgeries such as cholecystectomy carry more risks compared to elective ones, this patient’s lack of comorbidities and strong physical condition significantly lower his overall risk during the surgical process.
Patient 3 is a 75-year-old woman with a history of coronary artery disease, hypertension, and hyperlipidemia. She is classified as having an intermediate to high risk due to her multiple risk factors, including a history of coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI). Although she experiences hip pain that complicates the assessment of her functional status, her ejection fraction remains relatively stable at 55-60%, and she does not exhibit any current anginal or exertional symptoms. The echocardiogram indicates normal left ventricular function with no wall motion abnormalities, but her mobility is restricted due to hip pain. The surgical risk associated with a hip replacement is considered intermediate. While her age and comorbidities elevate her overall risk, it does not classify her as high-risk since she is currently stable and asymptomatic. According to the ACC/AHA guidelines and the Revised Cardiac Risk Index (RCRI), patients with several cardiac risk factors undergoing intermediate-risk surgeries, such as hip replacements, without active symptoms are categorized as intermediate risk. Risk Stratification Discussion Paper
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Conclusion
In summary, Patient 1 is classified as high risk due to severe aortic stenosis. Patient 3 falls into the intermediate to high-risk category because of multiple comorbidities, although they have a preserved ejection fraction. Conversely, Patient 2 is considered low risk, being young, active, and without any significant medical history. These classifications are derived from the use of risk stratification tools and a thorough assessment of each patient’s risk factors.
References
Carli, F., Baldini, G., & Feldman, L. S. (2021). Redesigning the preoperative clinic: From risk stratification to risk modification. JAMA Surgery, 156(2), 191. https://doi.org/10.1001/jamasurg.2020.5550
Johnson, E. P., Monsour, R., Hafez, O., Kotha, R., & Ackerman, R. S. (2024). Major perioperative cardiac risk assessment: A review for cardio-oncologists and perioperative physicians. Clinics and Practice, 14(3), 906–914. https://doi.org/10.3390/clinpract14030071
Sherrer, M., Simmons, J. W., & Dobyns, J. B. (2022). Preoperative risk stratification: Identifying modifiable risks for optimization. Current Anesthesiology Reports, 12(1), 10–25. https://doi.org/10.1007/s40140-022-00519-z
Yao, Y., Dharmalingam, A., Tang, C., Bell, H., DJ McKeown, A., McGee, M., Davies, A., Tay, T., & Collins, N. (2021). Cardiac risk assessment with the Revised Cardiac Risk Index index before elective non-cardiac surgery: A retrospective audit from an Australian tertiary hospital. Anaesthesia and Intensive Care, 49(6), 448–454. https://doi.org/10.1177/0310057×211024661 Risk Stratification Discussion Paper
Risk stratification is an important technique that allows patients to be classified according to their health risk status, taking into consideration many factors, such as diagnosis, age, BMI, comorbidities, labs and other assessment scores, health behaviors and health literacy, and social and caregiver support needs, to name a few. Utilizing such a framework or model can be used not only to identify patient-specific risks to refine treatment plants, but can also be applied to improve workflows, better manage population health, and effectively use resources.
For this Discussion, you will consider risk stratification in the preoperative environment.
Post your assessment of which level of risk each patient in the case scenarios corresponds with (high, intermediate, or low). Explain the rationale for your decision-making.
Discussion
You have a discussion due this week- please review the discussion forum requirements below:
Students are required to post an original response to each mandatory discussion question no later than day 3, Wednesday. Your post needs to be substantive and include a reference in APA format. Please be sure you support your arguments and analysis with references from reliable sources (i.e. Wikipedia is never an acceptable source) Risk Stratification Discussion Paper
Follow-up responses should be substantive and further the academic discussion. Substantive follow up posts need to be submitted no later than Day 6- Saturday.
Follow-up responses to classmate’s initial DQs that integrate course theories with a practical application of the subject, perhaps offering a personal observation or experience, or referencing real-world examples, current events, or presenting further research you have conducted on the topic.
Interaction in classroom discussion that demonstrates deeper or broader thoughts about a topic, rather than just rephrasing what the textbook has presented on the topic.
Posts that encourage further discussion and ongoing dialogue with other students and the instructor in the class.
Asking additional, relevant questions about the week’s topic.
All of your posts must be original. I am required by the school to spot-check for plagiarism and I do this every discussion- so please do not copy and paste any material into your responses
Take time to carefully review the grading rubric. I follow this rubric exactly when I assign points. Many students pass this course with just 1% above the cut-off, so do not miss points on the DQs!
Finally, please remember that all posts must be original and follow the school’s academic honest policy. Per school guidance I run the DQs through a plagiarism checker so please do not copy and paste any material into the discussions! Be sure you quote and reference any external material used to support your analysis- and write an original response to the question and your peers. This way everyone gains the highest quality learning experience from our interactions. Risk Stratification Discussion Paper
Week 1 Discussion Question Cases: NOTE: you are comparing all 3 patients, not picking just one. Be sure you clearly reference risk stratification tools in your analysis of the patients’ risk factors and how you apply them. Only use academic sources.
A 60-year-old female with no previous cardiac history, except for preoperative for stratification for a new murmur, is sent to you. An echocardiogram is performed demonstrating an ejection fraction of 60%, and severe aortic stenosis. Her proposed surgery is a total knee replacement.
A 25-year-old male is sent to you for preoperative risk stratification. His proposed surgery is an emergency cholecystectomy. He is active and has no exertional symptoms playing basketball for over an hour 3 times weekly. He has no previous cardiac, medical, or surgical history.
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A 75-year-old female with history of coronary artery disease with previous CABG and PCI, hypertension, and hyperlipidaemia is sent to you for preoperative risk stratification. Her proposed surgery is hip replacement. You are unable to assess her functional status due to hip pain, which renders her mobility challenged. Her previous echocardiogram demonstrates an ejection fraction of 55–60% with no wall motion abnormality. She has no active anginal or exertional symptoms. Risk Stratification Discussion Paper
