Preoperative Risk Stratification and Optimization Strategies in Noncardiac Surgery
In this expert Q&A, Nour Lyon, PA-C, physician assistant and an assistant professor at the University of Detroit Mercy, outlines practical strategies from her American Academy of Physician Associates (AAPA) 2025 presentation to help clinicians identify high-risk patients, implement evidence-based prehabilitation, and reduce day-of-surgery cancellations. One of the primary objectives of her presentation is to help clinicians learn how to integrate validated risk tools and clinical judgment to optimize outcomes in non-cardiac surgical care.
Consultant360: Can you discuss the key themes of your presentation at the AAPA 2025?
Nour Lyon, PA-C: Yes. There are two main themes in my presentation. First, I cover recent guidelines released in October, focused on identifying high-risk patients before non-cardiac surgery. Cardiac surgery is a whole different animal, so my presentation sticks to non-cardiac cases. The aim is to understand which tools we can use to identify high-risk individuals and guide them through safer, more effective surgical planning. Second, I focus on prehabilitation. Historically, the approach has been to operate first and address complications later. But the shift now is toward improving patients’ health beforehand—getting them in the best shape possible before surgery to improve post-op outcomes. This includes evidence-based interventions and guideline recommendations for optimizing patients preoperatively.
Consultant360: Why is this topic particularly relevant right now?
Nour Lyon: As surgery becomes more minimally invasive, there's a growing tendency to fast-track patients through clearance. But that's not always the safest approach. The preoperative space—especially from an anesthesia standpoint—hasn’t kept pace with surgical innovations. In our clinic, which is anesthesia-led, we focus on what can be done beforehand to improve outcomes. Another reason it’s important is that a thorough preoperative workup can reduce same-day surgery cancellations. Cancellations are costly for health systems. If we discover issues the day of surgery that could have been caught earlier, it affects efficiency and revenue. A proper workup helps optimize scheduling and ultimately improves outcomes.
Consultant360: What would be involved in that kind of preoperative workup?
Nour Lyon: At the University of Michigan, we have a focused preoperative clinic, which not many institutions offer. Surgeons appreciate it because we can catch things early—especially with medication reconciliation. Often, surgeries get canceled because a patient wasn’t told to stop a medication beforehand. Identifying these issues early helps us manage meds and avoid last-minute delays. We also screen for undiagnosed heart or lung conditions, which are critical to address before anesthesia.
Consultant360: What are the most important takeaways for clinicians from your presentation?
Nour Lyon: First, there are excellent risk calculators out there that many clinicians aren't familiar with. These tools help classify patients by risk level and guide pre-op decisions. Second, we need to emphasize optimization strategies. Things like proper medication management and thorough risk assessments can go a long way. Third, discovering undiagnosed conditions—especially cardiac and pulmonary—is essential. These are the systems most impacted by anesthesia, so identifying and managing issues in advance helps ensure safer surgeries.
Consultant360: Are there any knowledge gaps or areas of future research you're excited about?
Nour Lyon: Yes, several. For instance, frailty scores are promising for predicting complications, but we still don’t fully know how to act on those numbers—especially the ones that aren’t clearly high or low. Another area is the use of cardiac biomarkers preoperatively, like BNP and troponins. Early research shows they might predict surgical risk, but we don’t yet have standardized cutoff values or guidance on how to use them effectively. That’s an area ripe for future study.
Consultant360: Is there anything I missed that you’d like to add for our readers?
Nour Lyon: Yes. While calculators and tools are incredibly helpful, nothing replaces a good history and physical exam. At the end of the day, your clinical judgment—developed through training and experience—is what guides the final decision. The science and data support your decisions, but they are supplements, not replacements. Every patient is different, so we must always use a holistic approach in determining surgical readiness.
Reference
Lyon N. Prehabilitation: How Preoperative Medicine Can Optimize Patient Outcomes. Presented at the American Academy of Physician Associates (AAPA) 2025. https://aapa2025.eventscribe.net/searchGlobal.asp. Accessed May 9, 2025.