In a retrospective single-center study of 1,528 metabolic and bariatric surgery cases from 2014-2023, 56% of patients (n=852) were referred to cardiology pre-op — but 30% of those referrals (n=255) would have been avoided under a standardized risk algorithm, with about $28,000 in savings and no post-op cardiac complications. The study used RCRI plus age ≥65, smoking history, and/or METS ≤4 to identify which patients truly needed preoperative cardiac risk stratification.

Why It Matters To Your Practice

• NPs and PAs are often the clinicians who spot risk first, gather the functional-status history, and keep pre-op workups moving.

• This study suggests your front-end assessment can do more than support the surgeon — it can directly reduce low-value cardiology referrals.

• For bariatric candidates, a structured screen may help distinguish patients who need escalation from those safe to proceed without extra consults.

Clinical Benefits

• The proposed algorithm combined RCRI with ever-smoker status, age ≥65, and METS ≤4.

• Among referred patients, nearly 1 in 3 were low risk and potentially avoidable referrals under the algorithm.

• Of patients with RCRI=0, 45% (n=435) still underwent additional cardiac testing, highlighting a major opportunity to trim unnecessary workups.

• Patients referred to cardiology were older and more likely to have hypertension, hyperlipidemia, Diabetes mellitus (DM), heart failure, atrial fibrillation, smoking history, and BMI >50 kg/m2.

Managing Risks

• This was a retrospective analysis from one institution, so the algorithm should support — not replace — clinical judgment.

• No post-operative cardiac complications were reported, but that zero-event rate also limits certainty about rare adverse outcomes.

• Use caution in patients with poor exercise tolerance, multiple comorbidities, or symptoms that suggest active cardiac disease, even if a calculator labels them lower risk.

• Standardized screening works best when NPs and PAs have the authority to document METS, reconcile risk factors, and trigger referral only when criteria are met.

The Bottom Line

• Your assessment is not secondary — it is the decision point that can prevent unnecessary referrals while still protecting patient safety.

• In bariatric surgery candidates, a simple standardized pre-op cardiac screen may reduce low-yield cardiology consults, conserve resources, and streamline care.

• For frontline NPs and PAs, this is a strong case for protocol-driven autonomy in preoperative risk stratification.