New onset aflutter pre op... Cancel?

[ethilo]

75 year old, exercises 5x weekly, essentially otherwise healthy here for total knee arthroplasty, intake standard preop EKG on day of surgery patient has typical flutter with ventricular rate of 55, no evidence of ischemia. Pt is asymptomatic, hemodynamically stable, has no previous cardiac evaluation.

Would you cancel or proceed?

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[caveat87]

It’s an interesting question because the risk of embolism related to atrial flutter was always thought to be lower than atrial fibrillation. I remember talking to a cardiologist recently who said the role of TEE prior to atrial flutter cardioversion is unclear.

If you are in an inpatient setting I’d see if a cardiologist can come see the patient prior to canceling. They may say there is nothing to do and it’s fine to proceed. I’d probably delay if you are in an outpatient center but I’m also conservative when it comes to newfound arrhythmias that may benefit from medical optimization…

 

[coffeebythelake]

75 year old, exercises 5x weekly, essentially otherwise healthy here for total knee arthroplasty, intake standard preop EKG on day of surgery patient has typical flutter with ventricular rate of 55, no evidence of ischemia. Pt is asymptomatic, hemodynamically stable, has no previous cardiac evaluation.

Would you cancel or proceed?

He has good functional capacity and he will get AC postop anyways for DVT px. Would do it and consult cardiology afterwards. Hemodynamic stable. No evidence for CHF. You don't suspect some weird underlying pathology such as thyroid dz. Stroke risk measured in years not days

 

[GassYous]

No red flags is a green light to me

 

[Urzuz]

100% cancel.

New arrhythmia not previously diagnosed, completely elective surgery. The etiology of a new arrhythmia can range anywhere from benign nothingness to something that should be intervened on urgently, and you can’t confidently make that assessment from the preop holding area.

There’s absolutely nothing to be gained by proceeding, and literally if anything goes sideways, you will be writing a check.

 

[kidthor]

There’s absolutely nothing to be gained by proceeding, and literally if anything goes sideways, you will be writing a check.

Probably 95% of the time nothing will happen, and 5% of the time something will come up. The overlords will pressure you into doing the case and then when something comes up they'll blame you for not cancelling and will then suggest they'd have supported you if you ever had any safety concern (which is false). If the patient goes into RVR then you're to blame. Hell if the patient is at all tachycardic, has a DVT, a wound infection, pain, nausea, or challenges working with PT they might blame you too.

I'd personally convince the surgeon and patient to cancel on their own accord: "Do you really want to do surgery on someone with a new onset potentially unstable arrhythmia that increases the risk of death and surgical complications for this elective surgery?"

As a corollary do you want your airplane pilot to just go ahead when the engine light is alarming, or would you rather they get it checked out first?

 

[anbuitachi]

definitely cancel.

 

[DrOwnage]

Cancel just for the risk of low risk of stroke alone given his CHADSVASC of 1-2 (not sure if he's hypertensive). Never know, might throw in that spinal and his heart rate could jump to 140.

 

[Volatile]

Cancel

 

[deleted875186]

100% cancel. New onset a flutter needs workup by cardiology. I also agree that if anything happens, RVR during hosptial stay, DVT, ischemia, it is indefensible to proceed with an elective surgery in this case.

 

[coffeebythelake]

Interesting reaponses and thought processes. Thoughts if this wasn't a knee arthroplasty but something else?

Cataract surgery? Foot surgery under regional anesthesia? What if pt went into AF after regional anesthetic was administered but before incision made would you cancel?

Main worries with newly diagnosed Aflutter and Afib is hemodyanic instability.

 

[deleted875186]

Interesting reaponses and thought processes. Thoughts if this wasn't a knee arthroplasty but something else?

Cataract surgery? Foot surgery under regional anesthesia? What if pt went into AF after regional anesthetic was administered but before incision made would you cancel?

Main worries with newly diagnosed Aflutter and Afib is hemodyanic instability.

I disagree, my main concern is underlying disease process that led to the Aflutter, if it’s just a conduction abnormality, or if there is an underlying illness. I don’t know how often Aflutter is associated with ischemic heart disease, probably less so than Afib.

 

[ethilo]

I disagree, my main concern is underlying disease process that led to the Aflutter, if it’s just a conduction abnormality, or if there is an underlying illness. I don’t know how often Aflutter is associated with ischemic heart disease, probably less so than Afib.

That was my main concern too. We did, in fact, cancel him. This is major surgery with one of the highest risks of DVT formation, whereas cataract and carpal tunnel would be minor surgery / low risk.

I wasn't ENTIRELY sure what someone would do for his "workup." I had a few possible ideas of what they might do to check him out prior to his rescheduled surgery, I'm no cardiologist...
- Evaluate by taking a more thorough history for signs/sxs of ischemia?
- TTE to evaluate for WMA or valvular abnormalities?
- TEE to evaluate for LAA thrombus?
- Treadmill stress test? though patient is essentially doing this 5 days a week anyway without issue
- Start an antiarrhythmic drug? I think I've heard rhythm control is starting to be practiced preferentially over rate control

I have taken a patient to the OR with AFRVR for TKA before, mainly because the workup on that guy was exhaustive. He was followed closely by cardiology and they knew about it, patient was adamant they wanted surgery and understood the risks, he had all manner of cardiac diagnostic tests.

 

[ethilo]

At the same time... I can absolutely see the internist / cardiologist who receives this patient in clinic not knowing what to do with this guy. Something like 30% of geriatric patients develop Afib, some don't even know it's happening.

I mean, I think I'd feel pretty dumb when he shows up in clinic, they take an EKG, he's in sinus rhythm, and they say: there's nothing wrong with you, buh bye! I bet the patient would be pretty frustrated, even moreso than he already feels.

 

[hiyaman]

There was a previous thread about this before. Seems like most would consult cards and at least delay surgery. I think I would be inclined as well.

Tougher call to make if it's a cataract or other minor procedure at an asc as you would either have to proceed vs. cancel

 

[GravelRider]

This is an elective surgery in a patient with a newly diagnosed arrhythmia. This is a 100% easy cancel. Set the patient up to see a cardiologist and go grab a coffee while they rush the next patient through preop.

 

[DrOwnage]

By the time I debate whether or not to cancel a cataract we could have done the procedure already.

 

[Hoya11]

By the time I debate whether or not to cancel a cataract we could have done the procedure already.

right but its the liability to the ASC or yourself if RVR or nstemi develops you own it. i always cancel and send these folks to cardiologist if stable, ER if RVR or no available cardiologist. i would be ok if cardiologist says OK to proceed in a hospital setting via preop consult, you just have to run this through a cardiologist you cant own it

 

[OptionOffense]

75 year old, exercises 5x weekly, essentially otherwise healthy here for total knee arthroplasty, intake standard preop EKG on day of surgery patient has typical flutter with ventricular rate of 55, no evidence of ischemia. Pt is asymptomatic, hemodynamically stable, has no previous cardiac evaluation.

Would you cancel or proceed?

Why on earth would you get a pre op ekg on the day of surgery? Im sure protocol suggested it. Anyway, I'd do a spinal and tell them to follow up with fav cardiologist. There wont be any issues with it and Im certain the asymptomatic patient would want you to proceeed.

 

[IMGASMD]

Half of my tele admissions were “new onset a fib, r/o ACS”
Has hospital medicine changed that much? Even the ones with low risks, will at least get a set of trop at the ED then one more at 4 hr, before I/cards/EM would kick them out.

If it was new onset, it’s a definitely a no.

 

[coffeebythelake]

75 year old, exercises 5x weekly, essentially otherwise healthy here for total knee arthroplasty, intake standard preop EKG on day of surgery patient has typical flutter with ventricular rate of 55, no evidence of ischemia. Pt is asymptomatic, hemodynamically stable, has no previous cardiac evaluation.

Would you cancel or proceed?

Rate of 55? Is this patient taking a BB or diltiazem? Why would a patient with Aflutter be rate controlled? Are u sure it is flutter and not some tremor?

 

[coffeebythelake]

right but its the liability to the ASC or yourself if RVR or nstemi develops you own it. i always cancel and send these folks to cardiologist if stable, ER if RVR or no available cardiologist. i would be ok if cardiologist says OK to proceed in a hospital setting via preop consult, you just have to run this through a cardiologist you cant own it

Re cataract surgery and AFib or Aflutter, Recommendations from SAMBA say otherwise. Refer to Sweitzer et al 2021

 

[coffeebythelake]

I disagree, my main concern is underlying disease process that led to the Aflutter, if it’s just a conduction abnormality, or if there is an underlying illness. I don’t know how often Aflutter is associated with ischemic heart disease, probably less so than Afib.

So you are worried a patient with newly diagnosed (not necessary new onset) Atrial flutter that is rate controlled has an MI? Your EKG would show AF along with the ST changes and T wave abnormalities. This is someone who is awake, alert, completely asymptomatic and has great exercise tolerance? I think in this situation the likelihood of that is basically zero.

 

[coffeebythelake]

That was my main concern too. We did, in fact, cancel him. This is major surgery with one of the highest risks of DVT formation, whereas cataract and carpal tunnel would be minor surgery / low risk.

I wasn't ENTIRELY sure what someone would do for his "workup." I had a few possible ideas of what they might do to check him out prior to his rescheduled surgery, I'm no cardiologist...
- Evaluate by taking a more thorough history for signs/sxs of ischemia?
- TTE to evaluate for WMA or valvular abnormalities?
- TEE to evaluate for LAA thrombus?
- Treadmill stress test? though patient is essentially doing this 5 days a week anyway without issue
- Start an antiarrhythmic drug? I think I've heard rhythm control is starting to be practiced preferentially over rate control

That's the thing. The patient is already rate controlled, hemodynamically stable, and basically doing a stress test daily with his excellent exercise tolerance. He doesnt need a new rate or rhythm control medication. He does need to be on AC at some point but this can be safely deferred for days. He should follow up with cardiology at some point. Are you worried he might have a LAA thrombus ready to flick off? The only realistic thing one might do is check basic labs, maybe TSH, maybe BNP

I have taken a patient to the OR with AFRVR for TKA before, mainly because the workup on that guy was exhaustive. He was followed closely by cardiology and they knew about it, patient was adamant they wanted surgery and understood the risks, he had all manner of cardiac diagnostic tests.

This I would not have done. Uncontrolled AF for elective surgery?

 

[deleted875186]

So the recent oral board thread had an arguement about why the oral boards were irrelevant, because people don’t practice what they preach during the oral
Boards ….. not delaying this case would fail the oral boards, it’s indefensible, it’s also irresponsible in my opinion, we are anesthesiologists, patient needs to be worked up by someone who deals with Aflutter first.

 

[coffeebythelake]

So the recent oral board thread had an arguement about why the oral boards were irrelevant, because people don’t practice what they preach during the oral
Boards ….. not delaying this case would fail the oral boards, it’s indefensible, it’s also irresponsible in my opinion, we are anesthesiologists, patient needs to be worked up by someone who deals with Aflutter first.

Someone would fail their oral boards by making a kill move or something clearly inappropriate and committing to it. Oral boards is about decision making and more importantly the reasoning behind the decisions made. While I'm not a board examiner I doubt this is an "automatic fail" situation. (Not calling 911 after cardiac arrest in an office based surgicenter would be automatic fail though!)

 

[deleted875186]

Someone would fail their oral boards by making a kill move and committing to it. Oral boards is about decision making and more importantly the reasoning behind the decisions made. While I'm not a board examiner I doubt this is an "automatic fail" situation. (Not calling 911 after cardiac arrest in an office based surgicenter would be automatic fail though!)

I strongly disagree. I imagine you fail oral boards for making a decision without any sound reasoning that is unsafe. Proceeding with a case like this makes no sense, and is definitely unsafe.

 

[vector2]

So the recent oral board thread had an arguement about why the oral boards were irrelevant, because people don’t practice what they preach during the oral
Boards ….. not delaying this case would fail the oral boards, it’s indefensible, it’s also irresponsible in my opinion, we are anesthesiologists, patient needs to be worked up by someone who deals with Aflutter first.

This case is a cancel both on oral boards and in real life.

The cases of aflutter can vary from more benign things such as age, HTN, or even overexercising all the way to congenital heart disease, valvular disease, CHF, and CAD.

A pt telling you they have good exercise tolerance is not good enough to rule out the latter more worrisome causes, and until a cardiovascular disease expert has signed off that the aflutter isn't caused by the latter it's not a great idea proceeding.

 

[OptionOffense]

….. not delaying this case would fail the oral boards, it’s indefensible,

No it is not indefensible. One of your colleagues in this thread defended the practice. Proceeding on an elective case on a man who is totally asymptomatic and rate controlled is not an automatic fail. It is all how you package it.

 

[fakin' the funk]

75 year old, exercises 5x weekly, essentially otherwise healthy here for total knee arthroplasty, intake standard preop EKG on day of surgery patient has typical flutter with ventricular rate of 55, no evidence of ischemia. Pt is asymptomatic, hemodynamically stable, has no previous cardiac evaluation.

Would you cancel or proceed?

Flutter at 55? Sounds like Not Flutter

 

[CHARLESTONMMM]

I had this exact scenario play out a few months ago. Shows up in holding with rate controlled Afib. No prior history. Called his cardiologist and he said there’s nothing to do and recommended to proceed.

 

[coffeebythelake]

I had this exact scenario play out a few months ago. Shows up in holding with rate controlled Afib. No prior history. Called his cardiologist and he said there’s nothing to do and recommended to proceed.

Yes. Same. Pt with newly diagnosed rate controlled AF. Was taking metoprolol for HTN. Doesnt have a cardiologist. Good exercise tolerance. Spoke to patient after and consulted cardiology in recovery room. Cards said no worries, minimal symptoms, hemodynamically stable and rate controlled, so follow up outpatient in 3 days for evaluation, initiation or AC with eventual plan for TEE / DCCV

 

[coffeebythelake]

A pt telling you they have good exercise tolerance is not good enough to rule out the latter more worrisome causes, and until a cardiovascular disease expert has signed off that the aflutter isn't caused by the latter it's not a great idea proceeding.

So... can you explain the cardiac risk difference between a patient with known CAD and greater than 4 METS going for TKA, and this pt w rate controlled AF and greater than 4 METS who may but most likely do not have CAD? Why is >4 METS an acceptable method of assessing perioperative MACE risk for everyone other than AF?

 

[GravelRider]

That's the thing. The patient is already rate controlled, hemodynamically stable, and basically doing a stress test daily with his excellent exercise tolerance. He doesnt need a new rate or rhythm control medication. He does need to be on AC at some point but this can be safely deferred for days. He should follow up with cardiology at some point. Are you worried he might have a LAA thrombus ready to flick off? The only realistic thing one might do is check basic labs, maybe TSH, maybe BNP



This I would not have done. Uncontrolled AF for elective surgery?

The case is elective. I know there is pressure to get stuff done and be productive, but occasionally you have to apply the brakes and slow down. Not working a patient up with a newly diagnosed arrhythmia before an elective surgery is the wrong thing to do.

 

[ethilo]

Flutter at 55? Sounds like Not Flutter

Let me know what you think it is instead

 

[GravelRider]

I had this exact scenario play out a few months ago. Shows up in holding with rate controlled Afib. No prior history. Called his cardiologist and he said there’s nothing to do and recommended to proceed.

Your patient had a cardiologist, so I’m assuming had a cardiac history. If I know my cardiologists well, I can guess that your patient had recent work up…stress tests, caths, echos, etc. This patient in question has no prior cardiac disease and thus no prior cardiac work up. He needs a work up because people don’t flip into an arrhythmia just for fun.

Again, this case is elective. It’s not urgent and it’s certainly not emergent.

 

[anbuitachi]

i dont understand why so many people say sounds like not AF just bc rate is 55.
see slow ventricular rates in AF patients bunch of times...

 

[coffeebythelake]

The case is elective. I know there is pressure to get stuff done and be productive, but occasionally you have to apply the brakes and slow down. Not working a patient up with a newly diagnosed arrhythmia before an elective surgery is the wrong thing to do.

I refer you to definition of 'active cardiac conditions' in the perioperative guidelines for cardiovascular risk management. These are situations that should warrant additional cardiac evaluation and optimization prior to elective surgical procedurs. There is mention for atrial fibrillation here but specifically if it is not rate controlled.

So guidelines don't say I'm wrong. But you do. 🤷‍♂️

 

[deleted875186]

View attachment 352248

I refer you to definition of 'active cardiac conditions' in the perioperative guidelines for cardiovascular risk management. These are situations that should warrant additional cardiac evaluation and optimization prior to elective surgical procedurs. There is mention for atrial fibrillation here but specifically if it is no rate controlled.

So guidelines don't say I'm wrong. But you do.

Guidelines seem to be referring to known cardiac conditions, not undifferentiated and newly diagnosed arrhythmias.

 

[coffeebythelake]

Guidelines seem to be referring to known cardiac conditions, not undifferentiated and newly diagnosed arrhythmias.

Incorrect. For instance, what part of "newly recognized ventricular tachycardia" says that it is a previously known cardiac condition?

 

[deleted875186]

View attachment 352248

I refer you to definition of 'active cardiac conditions' in the perioperative guidelines for cardiovascular risk management. These are situations that should warrant additional cardiac evaluation and optimization prior to elective surgical procedurs. There is mention for atrial fibrillation here but specifically if it is no rate controlled.

So guidelines don't say I'm wrong. But you do. 🤷‍♂️

I don’t believe the guidelines address all clinical scenarios. For instance, the guidelines recommend against preoperative screening echocardiograms if I remember correctly, but if a patient came in for an elective procedure with a loud murmur that has never been mentioned before, would you proceed on the grounds that they were asymptomatic, had >4 METS, no SOB, or would you get the echo to better define yojr hemodynamics goals?

 

[coffeebythelake]

I don’t believe the guidelines address all clinical scenarios. For instance, the guidelines recommend against preoperative screening echocardiograms if I remember correctly, but if a patient came in for an elective procedure with a loud murmur that has never been mentioned before, would you proceed on the grounds that they were asymptomatic, had >4 METS, no SOB, or would you get the echo to better define yojr hemodynamics goals?

Lets stay on focus. You claim that the guidelines do not address all clinical scenarios. But in the case of arrhythmias it SPECIFICALLY describes the subset of supraventricular tachycardias that warrant evaluation. If the guidelines explicitly say AFIB with resting ventricular rates OVER 100 require evaluation, what do you think it is saying about AFIB with resting ventricular rates LESS than 100? I'm not saying these patients shouldn't see a cardiologist at some point, just that they don't absolutely need to see them before the surgery.

 

[coffeebythelake]

I don’t believe the guidelines address all clinical scenarios. For instance, the guidelines recommend against preoperative screening echocardiograms if I remember correctly, but if a patient came in for an elective procedure with a loud murmur that has never been mentioned before, would you proceed on the grounds that they were asymptomatic, had >4 METS, no SOB, or would you get the echo to better define yojr hemodynamics goals?

To rephrase, what you are asking is this:

"How do I know a patient has severe aortic stenosis, or severe mitral stenosis if they have a murmur and never had an echo?


**This is an issue relating to the diagnosis of the valvular abnormality, not an issue of defining what is actually the valvular abnormality that warrants cardiologist referral**,

To Make The Diagnosis: You might do a bedside echo, or if you don't know how to you might decide to get a formal TTE... but you don't send a patient to the cardiologist for cardiac evaluation and optimization because of a murmur. To reiterate this point... if you palpate a patient's pulse in preop and felt irregularly irregular heart rate at 120, you order a 12-lead EKG to make the diagnosis. You don't just send the patient to the cardiologist so they can make the diagnosis for you.

You say that guidelines recommend against preoperative screening echocardiograms. But if a patient has a murmur that make you worried about hemodynamically significant pathology, then this isn't a screening examination is it?

 

[GravelRider]

View attachment 352248

I refer you to definition of 'active cardiac conditions' in the perioperative guidelines for cardiovascular risk management. These are situations that should warrant additional cardiac evaluation and optimization prior to elective surgical procedurs. There is mention for atrial fibrillation here but specifically if it is not rate controlled.

So guidelines don't say I'm wrong. But you do. 🤷‍♂️

2.5. Arrhythmias and Conduction Disorders​

Cardiac arrhythmias and conduction disorders are common findings in the perioperative period, particularly with increasing age. Although supraventricular and ventricular arrhythmias were identified as independent risk factors for perioperative cardiac events in the Original Cardiac Risk Index,48 subsequent studies indicated a lower level of risk.37,90,91 The paucity of studies that address surgical risk conferred by arrhythmias limits the ability to provide specific recommendations…..Nevertheless, the presence of an arrhythmia in the preoperative setting should prompt investigation into underlying cardiopulmonary disease, ongoing myocardial ischemia or MI, drug toxicity, or metabolic derangements, depending on the nature and acuity of the arrhythmia and the patient’s history.


Yeah, I’m still cancelling.

 

[coffeebythelake]

Although supraventricular and ventricular arrhythmias were identified as independent risk factors for perioperative cardiac events in the Original Cardiac Risk Index, subsequent studies indicated a lower level of risk. The paucity of studies that address surgical risk conferred by arrhythmias limits the ability to provide specific recommendations…..Nevertheless, the presence of an arrhythmia in the preoperative setting should prompt investigation into underlying cardiopulmonary disease, ongoing myocardial ischemia or MI, drug toxicity, or metabolic derangements, depending on the nature and acuity of the arrhythmia and the patient’s history.

I took the liberty of highlighting some key qualifying phrases in your quote.

Yeah, I’m still cancelling.

Read the first 5 words. This is a blanket statement about ALL supraventricular and ventricular arrhythmias, and it is reflected in the up to date ACC/AHA guidelines listed above. Notwithstanding the fact that different types of arrhythmias have varying levels of intraoperative risk... again as reflected in the up to date ACC/AHA guidelines listed above. Notwithstanding the key qualifying statement about how the "nature and acuity of the arrhythmia and the patient's history" should guide your decision making.

But that's fine if you interpret that wishy washy statement and decide to cancel for an asymptomatic, rate controlled atrial flutter patient.

To say another anestheisologist is unsafe and pushing things through because of "production pressure" is uncalled for

 

[coffeebythelake]

At the same time... I can absolutely see the internist / cardiologist who receives this patient in clinic not knowing what to do with this guy. Something like 30% of geriatric patients develop Afib, some don't even know it's happening.

I mean, I think I'd feel pretty dumb when he shows up in clinic, they take an EKG, he's in sinus rhythm, and they say: there's nothing wrong with you, buh bye! I bet the patient would be pretty frustrated, even moreso than he already feels.

The internist or cardiologist would ensure that the patient is rate or rhythm controlled to prevent long term tachyarrhythmia related oschemia or cardiomyopathy, and initiated on some type of anticoagulation depending on CHA2DS2VASc score to prevent long term stroke risk, perform some lab or imaging studies if appropriate, arrange follow up care, and possibly refer to EP for cardioversion or ablation therapy if warranted. This does not necessarily mean it has to happen right away. And this follow up and management plan would exist even if the patient spontaneously converted back to sinus rhythm when they show up in the cardiologist clinic.

 

[coffeebythelake]

It's actually interesting reading through this thread, and looking back at old threads on SDN about this very same topic. Newly diagnosed AF, what to do. Cancel? Proceed? The discussions and comments from both sides never change.

 

[Planktonmd]

New onset arrhythmia on a patient getting elective surgery means cancel the case and get cardiology consult.
It's not because there is solid science to support this approach, but because most reasonable people don't enjoy dealing with malpractice lawyers and spending time in depositions being accused of incompetence. You will be blamed for any complication even if unrelated.

 

[GravelRider]

I took the liberty of highlighting some key qualifying phrases in your quote.



That's fine if you interpret that wishy washy statement and decide to cancel.
But to call someone out as being unsafe and pushing things through because of "production pressure" is uncalled for

I didn’t say you were unsafe, I said it was the wrong thing to do. Low level of risk doesn’t mean no risk. Again, I emphasize this is an elective case with no urgency. Why proceed here? What do you gain? The risk of postponing the case 1 week is really just inconvenience. The risk of doing the case and having a major cardiac event perioperatively is low, but not zero. Why would I not try to make that risk as low as possible? The guy is 75 years old with new onset arrhythmia. He needs a cardiac workup and I would rather it get done before he has surgery.

Sometimes when those “wishy washy” academic statements don’t take a stand, I use the loved one rule of thumb. If this patient was my father, I would want the surgery cancelled.

Do the case. It’ll probably be fine, but every once in a while it won’t be fine and you’ll be wishing you cancelled it when you could.

 

[Beeftenderloin]

I would cancel this elective case, or at the very least delay until evaluation by cardiology, same day or otherwise. I’m not cancelling/delaying BECAUSE of the a-flutter. I’m cancelling/delaying because neither I nor anybody else has done any investigation whatsoever into the etiology (Structural disease, ischemia, infiltrative, infectious, thyroid, lytes, pharmacologic or otherwise). Maybe they’re extremely fit and active and when you asked if they can walk 4 blocks they said “of course I can, I run 2 miles 3 times per week” but they aren’t telling you they used to run 5 miles but they’ve been getting tired and having to stop earlier and earlier for the past year and are only doing 2 miles now. I wouldn’t think someone was crazy for proceeding though, it probably goes off without a hitch 9/10 times.