Under the bright, early‑morning glow of a Vegas ballroom—think less blackjack table, more brightly lit lecture hall—two perioperative medicine rivals took the stage for SHM’s “Great Debate.” Joan M. Irizarry-Alvarado, MD, FACP, DFPM, assistant professor of medicine and anesthesiology at Mayo Clinic in Jacksonville, Fla., and Edie Shen, MD, DFPM, clinical associate professor of medicine at the University of Washington in Seattle, inherited the tongue‑in‑cheek “East Coast versus West Coast” smack‑talk tradition from their mentors, but the frivolity quickly gave way to two tightly argued clinical controversies.
Before each case, the audience voted, then heard dueling seven-minute mini‑lectures. The debaters were bound by four ground rules laid down by their predecessors: no profanity, no thrown objects, no prior knowledge of each other’s slides, and no mercy. The “godfathers” of perioperative medicine sat in the front row, poised to render a final verdict.
Case 1 — Recent DES, urgent cancer surgery
The patient: A 63-year-old man who received drug-eluting stents (left anterior descending and right coronary artery) six weeks ago after a non-ST-elevation myocardial infarction, now requires resection of a rapidly enlarging head and neck tumor. He is still on dual antiplatelet therapy (DAPT). The surgical oncologist insists the tumor will become unresectable with additional delay.
Dr. Irizarry-Alvarado: Admit for IV cangrelor
Dr. Irizarry-Alvarado argued that cancer-related time pressure outweighs the classical “wait three months” rule. Citing the CHAMPION PHOENIX and BRIDGE trials, he highlighted cangrelor’s rapid, reversible P2Y12 inhibition (90% platelet blockade in five minutes, wash‑out within an hour), noting multiple case reports of successful bridging with minimal bleeding. Guidelines now offer a grade 2A endorsement for IV P2Y12 bridging when surgery is time‑sensitive, but DAPT can’t safely continue. For this high-risk oncology patient, Dr. Irizarry-Alvarado framed cangrelor as “an elegant Vegas side‑bet: limited downside, potentially life-saving upside.”
Dr. Shen: Skip the bridge, operate on aspirin alone
Dr. Shen called the cangrelor plan a mirage, “flashy like the Strip, but mostly neon.” She presented registry data showing the excess risk of perioperative myocardial infarction and mortality plummeting after the first post-stent month; by six weeks, risk approximates that of stable coronary artery disease. Multiple modern randomized controlled trials of second-generation stents show little penalty when DAPT is interrupted after 30 days. The U.S. Food and Drug Administration advisory panel’s 9 to 0 vote against bridging for surgery, plus the drug’s eye-watering cost (and likely pre‑op hospitalization), make cangrelor “low‑value care.” Finally, meta-analyses of IV GPIIb/IIIa bridging demonstrate higher bleeding without ischemic benefit—a cautionary analogue.
Audience swing and expert commentary
After both spiels, the audience shifted decisively toward Dr. Shen’s aspirin-only plan. The senior discussants agreed: outside the first month, routine bridging is rarely justified; individual anatomy and cardiology input matter more than reflexive protocols. They reminded the crowd that value-based care demands proof of net clinical benefit, not just theoretical safety.
Case 2 — Hip fracture with decompensated heart failure
The patient: A 75-year-old woman with an ejection fraction of 30 to 35%, prior percutaneous coronary intervention two years ago, and a new displaced femoral neck fracture after a fall. On arrival, she is seven pounds above dry weight, orthopneic on 4 L/min oxygen, and 2+ edematous. A single 40 mg IV furosemide dose produces 1.2 L of urine overnight; the next morning, she still needs 2.5 L/min of oxygen and has residual edema. Ortho has an operating room (OR) slot in a few hours.
Dr. Shen: Delay up to 24 hours for aggressive diuresis
Dr. Shen, switching to the affirmative, noted that not all delays are created equal. Large observational cohorts show no mortality benefit for surgery at less than 24 hours versus less than 48 hours when the postponement is used to correct major physiological abnormalities. Guidelines from the American Academy of Orthopaedic Surgeons and ACS‑TQIP both define “timely” as within 48 hours. UpToDate (and common sense) recommend stabilizing decompensated heart failure—even if that pushes surgery past the 24-hour mark. Using heatmap data correlating Charlson score, age, and time-to-OR, she illustrated how unoptimized chronic heart failure quadruples postoperative complications and pushes 30-day mortality to grim heights. “You wouldn’t play roulette on an unbalanced wheel,” she quipped.
Dr. Irizarry-Alvarado: Get her to the OR today
Dr. Irizarry-Alvarado countered that every 24-hour delay increases pneumonia, pressure ulcers, and delirium—morbidities equally lethal in frail elders. Meta-analysis of 16 studies demonstrates lower mortality and fewer complications when hip fracture repair occurs within 24 hours. HIP‑ATTACK’s accelerated‑surgery arm showed reduced delirium, pain, and discharge time; patients, administrators, and families all win. Delays for echocardiography can triple the length of stay and are themselves linked to infections, thromboembolism, and higher six-month mortality. Dr. Irizarry-Alvardo’s bottom line: half‑measures (like a single 40 mg furosemide dose) are inadequate; instead, “prune her aggressively overnight” with high-dose diuretics, reassess creatinine at dawn, and wheel her to the OR.
Audience Swing and Expert Commentary
The room split almost 50/50. The veteran commentators reconciled the impasse:
- Volume status, oxygen requirement, and expected blood loss dictate timing more than a blanket hour‑count.
- Anesthesiology’s insight into intra‑op fluid shifts may clarify whether another half‑day of diuresis truly reduces risk.
- Prioritize mobilization. Every postponement should be justified by tangible physiological improvement, not scheduling convenience.
In the end, the “OG mobsters”, Kurt Pfeifer, MD, FACP, SFHM, professor of medicine at the medical college of Wisconsin in Milwaukee, Wis., and Steven Cohn, MD, MACP, SFHM, professor emeritus at University of Miami Miller School of Medicine in Miami, reminded attendees that while guidelines provide the rules of play, perioperative medicine remains a dynamic game of probabilities, context, and patient‑centered negotiation—much like knowing when to hold ’em, when to fold ’em, and when the safest move is to step away from the table.
Key Takeaways
- Bridging after modern DES: Outside the first month, data favor stopping the P2Y12 agent and proceeding on aspirin rather than gambling on costly IV substitutes.
- Hip fracture timing: Aim for under 24 hours when the patient is stable, but accept up to 48 hours when evidence-based optimization (not bureaucratic delay) is underway.
- Evidence hierarchy still rules the table. Small trials, registry slices, and pathophysiology can hint at strategy, but the house edge belongs to well-powered randomized controlled trials—don’t bet big on anything less robust.
- Talk to your teammates. Surgeon urgency, anesthetic plan, and cardiology or heart‑failure input should always be stacked before you place your chips.
Dr. Migliore is an assistant professor of medicine at Columbia University College of Physicians and Surgeons, director of general medicine perioperative, and consult services, and medical director of surgery and surgical step-down at Columbia University Medical Center in New York.