2022 ESC Guidelines on cardiovascular assessment and management of patients undergoing non-cardiac surgery
Reported from ESC Congress 2022
The above guideline was published during the 2022 ESC Congress in Barcelona and was chaired by Professor Julinda Mehilli (Germany) and Professor Sigrun Halvorsen (Norway). This guideline was developed by the task force for cardiovascular assessment and management of patients undergoing non-cardiac surgery of the European Society of Cardiology (ESC) and Endorsed by the European Society of Anaesthesiology and Intensive Care (ESAIC).
Vijay Kunadian shares with you the key elements and take-home messages.
Cardiologists are often consulted by our surgical or anaesthetic colleagues prior to non-cardiac surgery for patients with history of cardiovascular disease or at risk of cardiovascular disease or upon detection of new cardiovascular symptoms/findings such heart murmurs, angina, dyspnoea or oedema. There is no currently clear consensus or guidelines on the optimal management of such patients.
Background and why is there a need for such a guideline?
- The annual volume of major surgery worldwide is estimated to be >300 million patients (about 5% of the world population).
- Nearly half of adults aged ≥45 years undergoing major non-cardiac surgery (NCS) present with:
- At least two cardiovascular risk factors
- 18% have coronary artery disease
- 4.7% have a history of stroke
- 7.7% had a modified Revised Cardiac Risk Index (RCRI) score ≥3
- The rates of NCS after PCI were 11% and 24%, 1 and 3 years after PCI respectively.
- The cut-off ages at which NCS was more likely to occur within 1 and 3 years of PCI were 62 and 73 years respectively
Importantly our population is rapidly ageing. As a result, the number of patients in need of non-cardiac surgery (NCS) continues to increase.
- Up to 8% of these patients require critical care admission with a mean in-hospital mortality of 4% resulting in >4 million post-operative deaths every year.
- The risk of cardiovascular morbidity and mortality in patients undergoing NCS is the result of an interplay between patients-related risk and the intrinsic risk of surgery dependent on the circumstances under which it takes place (immediate, urgent, time-sensitive and elective) and its type (low, intermediate, and high risk).
Therefore, there is a need for a clear guideline on the management of patients undergoing NCS to reduce the peri-operative complications and improve outcomes. The 2022 ESC NCS guideline addresses many of these important factors.
Risk assessment and risk reduction strategies
The new 2022 ESC guideline for cardiac patients in need of NCS provides a new and easy-to-use strategy for pre-operative risk assessment.
There is no specific risk score to assess patient-related risk. However, the following variables have been proposed as triggers for further risk assessment procedures.
- Patient age (>65years)
- Presence/absence of cardiovascular risk factors
- Presence/absence of cardiovascular diseases
Biomarker measurements:
Use of serial biomarkers measurements (hs-cardiac Troponin T/I) for patients undergoing intermediate or high-risk NCS is recommended for both pre-operative risk stratification and for diagnosis of peri-operative myocardial infarction.
Frailty assessment:
The peri-operative evaluation of older patients who require elective major NCS should include frailty screening, which has proven to be an excellent predictor of unfavourable health outcomes in the older surgical population.
Risk-reduction strategies in patients with specific diseases
For patients with CAD, the cardiac-work up is recommended for patients undergoing intermediate or high-risk NCS.
- Non-invasive CCTA should be considered to rule out CAD in patients with suspected CCS or biomarker-negative NSTE-ACS in case of low-to-intermediate clinical likelihood of CAD, or in patients not suitable for non-invasive functional testing undergoing non-urgent, intermediate-, and high-risk NCS (class IIa, LOE C)
For patients with severe aortic valve stenosis (AS), valve treatment depends on the presence/absence of symptoms, risk of NCS and the patients’ risk for valve procedures.
- For symptomatic AS patients in need of intermediate- or high-risk NCS valve repair (SAVR or TAVI) is recommended while in case of time-sensitive NCS rescue balloon valvuloplasty may be considered before NCS as bridge to definitive aortic valve repair (class IIb, LOE C)
Assessment and detection of the risk of perioperative complications
The most frequent peri-operative complications are perioperative myocardial injury/infarction (PMI), acute heart failure, arrythmias, stroke and pulmonary embolism leading to cardiovascular death.
PMI is most frequent complication which is largely asymptomatic (<90%) due to anaesthesia and analgesia.
- High awareness for peri-operative CV complications combined with surveillance for PMI in patients undergoing intermediate- or high-risk NCS (class I, LOE B).
- Serial measurements of hs-cT combined with ECG and TTE are key components of PMI detection.
- A systematic PMI work-up is recommended to identify the underlying pathology and to define therapy (class I, LOE B).
- In case of peri-operative ACS, acute heart failure or tachyarrhythmias, treatment in accordance with guidelines for the non-surgical setting, after interdisciplinary discussion with the surgeon about bleeding risk is recommended (class I, LOE C)
- Pre-operative use of beta-blockers to prevent peri-operative atrial fibrillation is not recommended (class III, LOE B)
New sections
A new section related to risk assessment of patients with newly detected cardiac murmur, angina, dyspnea or peripheral oedema has been added to the guideline.
- Transthoracic echocardiography has a class I indication in these situations.
In the general risk assessment strategies, the guideline recommends:
- Smoking cessation >4 weeks before NCS (class I LOE B)
- Optimize guideline-recommended treatment of CVD and CV risk factors if time allows before NCS (class I LOE C).
- Bridging of OAC therapy is not recommended in patients with low/moderate thrombotic risk undergoing NCS (class III, LOE B).
Communication to patients
The guideline emphasises the importance of clear and concise communication with patients, using simple verbal and written instructions about medication changes in the pre- and post-operative phases.
Take home messages
- Our population is ageing with high levels of co-morbidities in need of non-cardiac surgery
- Clear assessment of risk and risk reduction strategies must be implemented to reduce peri-operative complications and improve outcomes in this high-risk patient population
- Investigations such as cardiac biomarkers, ECG, CCTA, echocardiography and frailty assessments are recommended based on the clinical scenario of the patients.
- The guideline recommends to optimise guideline-recommended treatment of CVD and CV risk factors
- Clear and concise communication of changes in medication should be provided to patients.
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