2014 ESC/ESA Guidelines on non-cardiac surgery

49 Pages·2014·4.73 MB·English

ESC/ESA GUIDELINES
EuropeanHeartJournal(2014)35,2383–2431
doi:10.1093/eurheartj/ehu282
2014 ESC/ESA Guidelines on non-cardiac surgery:
cardiovascular assessment and management
The Joint Task Force on non-cardiac surgery: cardiovascular
assessment and management of the European Society of Cardiology
(ESC) and the European Society of Anaesthesiology (ESA)
Authors/Task ForceMembers: Steen Dalby Kristensen* (Chairperson) (Denmark),
Juhani Knuuti*(Chairperson) (Finland), Antti Saraste(Finland), Stefan Anker
(Germany), Hans Erik Bøtker(Denmark), Stefan DeHert (Belgium), Ian Ford (UK),
Jose Ramo´nGonzalez-Juanatey(Spain), Bulent Gorenek (Turkey),
Guy Robert Heyndrickx(Belgium), Andreas Hoeft (Germany), Kurt Huber (Austria),
Bernard Iung (France), Keld Per Kjeldsen (Denmark), Dan Longrois(France),
Thomas F.Lu¨scher (Switzerland), Luc Pierard (Belgium), Stuart Pocock (UK),
Susanna Price (UK), Marco Roffi (Switzerland),Per Anton Sirnes (Norway),
Miguel Sousa-Uva (Portugal), Vasilis Voudris (Greece), Christian Funck-Brentano
(France).
ESCCommitteeforPracticeGuidelines:JoseLuisZamorano(Chairperson)(Spain),StephanAchenbach(Germany),
HelmutBaumgartner(Germany),JeroenJ.Bax(Netherlands),He´ctorBueno(Spain),VeronicaDean(France),
ChristiDeaton(UK),CetinErol(Turkey),RobertFagard(Belgium),RobertoFerrari(Italy),DavidHasdai(Israel),
ArnoW.Hoes(Netherlands),PaulusKirchhof(Germany/UK),JuhaniKnuuti(Finland),PhilippeKolh(Belgium),
PatrizioLancellotti(Belgium),AlesLinhart(CzechRepublic),PetrosNihoyannopoulos(UK),MassimoF.Piepoli
(Italy),PiotrPonikowski(Poland),PerAntonSirnes(Norway),JuanLuisTamargo(Spain),MichalTendera(Poland),
AdamTorbicki(Poland),WilliamWijns(Belgium),StephanWindecker(Switzerland).
ESAClinicalGuidelinesCommittee:MaurizioSolca(Chairperson)(Italy),Jean-Franc¸oisBrichant(Belgium),
StefanDeHerta,(Belgium),EdoardodeRobertisb,(Italy),DanLongroisc,(France),SibylleKozekLangenecker
(Austria),JosefWichelewski(Israel).
*Corresponding authors: Steen Dalby Kristensen, Dept. of Cardiology, Aarhus University Hospital Skejby, Brendstrupgardsvej, 8200 Aarhus Denmark. Tel: [phone];
Fax:[phone];Email:[email protected].
JuhaniKnuuti,TurkuUniversityHospital,Kiinamyllynkatu4–8,P.O.Box52,FI-20521TurkuFinland.Tel:[phone];Fax:[phone];Email:juhani.knuuti@utu.fi
ThecontentoftheseEuropeanSocietyofCardiology(ESC)Guidelineshasbeenpublishedforpersonalandeducationaluseonly.Nocommercialuseisauthorized.NopartoftheESC
GuidelinesmaybetranslatedorreproducedinanyformwithoutwrittenpermissionfromtheESC.PermissioncanbeobtaineduponsubmissionofawrittenrequesttoOxfordUniversity
Press,thepublisheroftheEuropeanHeartJournalandthepartyauthorizedtohandlesuchpermissionsonbehalfoftheESC.
OtherESCentitieshavingparticipatedinthedevelopmentofthisdocument:
ESCAssociations:AcuteCardiovascularCareAssociation(ACCA);EuropeanAssociationforCardiovascularPrevention&Rehabilitation(EACPR);EuropeanAssociationofCardiovas-
cularImaging(EACVI);EuropeanAssociationofPercutaneousCardiovascularInterventions(EAPCI);EuropeanHeartRhythmAssociation(EHRA);HeartFailureAssociation(HFA).
ESCCouncils:CouncilforCardiologyPractice(CCP);CouncilonCardiovascularPrimaryCare(CCPC).
ESCWorkingGroups:CardiovascularPharmacologyandDrugTherapy;CardiovascularSurgery;HypertensionandtheHeart;NuclearCardiologyandCardiacComputedTomography;
Thrombosis;ValvularHeartDisease.
Disclaimer.TheESCGuidelinesrepresenttheviewsoftheESCandwereproducedaftercarefulconsiderationofthescientificandmedicalknowledgeandtheevidenceavailableatthe
timeoftheirdating.TheESCisnotresponsibleintheeventofanycontradiction,discrepancyand/orambiguitybetweentheESCGuidelinesandanyotherofficialrecommendationsor
guidelinesissuedbytherelevantpublichealthauthorities,inparticularinrelationtogooduseofhealthcareortherapeuticstrategies.HealthprofessionalsareencouragedtotaketheESC
Guidelinesfullyintoaccountwhenexercisingtheirclinicaljudgmentaswellasinthedeterminationandtheimplementationofpreventive,diagnosticortherapeuticmedicalstrategies;
however,theESCGuidelinesdonotoverride,inanywaywhatsoever,theindividualresponsibilityofhealthprofessionalstomakeappropriateandaccuratedecisionsinconsiderationofthe
conditionofeachpatient’shealthandinconsultationwiththatpatientand,whereappropriateand/ornecessary,thepatient’scaregiver.NordotheESCGuidelinesexempthealthprofes-
sionalsfromtakingfullandcarefulconsiderationoftherelevantofficialupdatedrecommendationsorguidelinesissuedbycompetentpublichealthauthoritiesinordertomanageeach
patient’scaseinthelightofthescientificallyaccepteddatapursuanttotheirrespectiveethicalandprofessionalobligations.Itisalsothehealthprofessional’sresponsibilitytoverifythe
applicablerulesandregulationsrelatingtodrugsandmedicaldevicesatthetimeofprescription.
&TheEuropeanSocietyofCardiology2014.Allrightsreserved.Forpermissionspleaseemail:[email protected].
2384 ESC/ESAGuidelines
DocumentReviewers:MassimoF.Piepoli(Reviewco-ordinator)(Italy),WilliamWijns(Reviewco-ordinator)
(Belgium),StefanAgewall(Norway),ClaudioCeconi(Italy),AntonioCoca(Spain),UgoCorra` (Italy),
RaffaeleDeCaterina(Italy),CarloDiMario(UK),ThorEdvardsen(Norway),RobertFagard(Belgium),
GiuseppeGermano(Italy),FabioGuarracino(Italy),ArnoHoes(Netherlands),TorbenJoergensen(Denmark),
PeterJu¨ni(Switzerland),PedroMarques-Vidal(Switzerland),ChristianMueller(Switzerland),O¨ztekinOto(Turkey),
PhilippePibarot(Canada),PiotrPonikowski(Poland),OlavFMSellevold(Norway),FilipposTriposkiadis(Greece),
StephanWindecker(Switzerland),PatrickWouters(Belgium).
ESCNationalCardiacSocietiesdocumentreviewerslistedinappendix.
ThedisclosureformsoftheauthorsandreviewersareavailableontheESCwebsitewww.escardio.org/guidelines
aScientificCommitteeChairperson&ESABoardRepresentative;bNASCChairperson;andcEBA/UEMSrepresentative
Onlinepublish-ahead-of-print1August2014
Seepage2342fortheeditorialcommentonthisarticle(doi:10.1093/eurheartj/ehu295)
------------------------------------------------------------------------------------------------------------------------------------------------------
Keywords Guidelines † Non-cardiacsurgery † Pre-operativecardiacriskassessment † Pre-operativecardiactesting †
Pre-operativecoronaryarteryrevascularization † Perioperativecardiacmanagement † Anti-thrombotic
therapy † Beta-blockers † Valvulardisease † Arrhythmias † Heartfailure † Renaldisease † Pulmonary
disease † Cerebrovasculardisease † Anaesthesiology † Post-operativecardiacsurveillance
Table of Contents
Abbreviationsandacronyms . . . . . . . . . . . . . . . . . . . . . . .2385 4.3.3 Reversalofanticoagulanttherapy . . . . . . . . . . . .2402
1. Preamble . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2386 4.4 Revascularization. . . . . . . . . . . . . . . . . . . . . . . . . .2403
2. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2387 4.4.1 Prophylacticrevascularizationinpatientswith
2.1 Themagnitudeoftheproblem. . . . . . . . . . . . . . . . .2387 asymptomaticorstableischaemicheartdisease. . . . . . . .2404
2.2 Changeindemographics. . . . . . . . . . . . . . . . . . . . .2387 4.4.2 Typeofprophylacticrevascularizationinpatients
2.3 Purposeandorganization . . . . . . . . . . . . . . . . . . . .2387 withstableischaemicheartdisease . . . . . . . . . . . . . . . .2405
3. Pre-operativeevaluation . . . . . . . . . . . . . . . . . . . . . . . .2389 4.4.3 Revascularizationinpatientswithnon-ST-elevation
3.1 Surgicalriskforcardiacevents . . . . . . . . . . . . . . . . .2389 acutecoronarysyndrome. . . . . . . . . . . . . . . . . . . . . .2405
3.2 Typeofsurgery. . . . . . . . . . . . . . . . . . . . . . . . . . .2389 5. Specificdiseases. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2406
3.2.1 Endovascularvs.openvascularprocedures . . . . . .2389 5.1 Chronicheartfailure . . . . . . . . . . . . . . . . . . . . . . .2406
3.2.2 Openvs.laparoscopicorthoracoscopicprocedures. .2390 5.2 Arterialhypertension. . . . . . . . . . . . . . . . . . . . . . .2408
3.3 Functionalcapacity. . . . . . . . . . . . . . . . . . . . . . . . .2390 5.3 Valvularheartdisease. . . . . . . . . . . . . . . . . . . . . . .2408
3.4 Riskindices . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2391 5.3.1 Patientevaluation . . . . . . . . . . . . . . . . . . . . . .2408
3.5 Biomarkers . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2392 5.3.2 Aorticstenosis . . . . . . . . . . . . . . . . . . . . . . . .2408
3.6 Non-invasivetesting. . . . . . . . . . . . . . . . . . . . . . . .2392 5.3.3 Mitralstenosis. . . . . . . . . . . . . . . . . . . . . . . . .2409
3.6.1 Non-invasivetestingofcardiacdisease. . . . . . . . .2393 5.3.4 Primaryaorticregurgitationandmitralregurgitation2409
3.6.2 Non-invasivetestingofischaemicheartdisease. . . .2393 5.3.5 Secondarymitralregurgitation . . . . . . . . . . . . . .2409
3.7 Invasivecoronaryangiography . . . . . . . . . . . . . . . . .2395 5.3.6 Patientswithprostheticvalve(s) . . . . . . . . . . . . .2409
4. Risk-reductionstrategies . . . . . . . . . . . . . . . . . . . . . . . .2395 5.3.7 Prophylaxisofinfectiveendocarditis. . . . . . . . . . .2409
4.1 Pharmacological . . . . . . . . . . . . . . . . . . . . . . . . . .2395 5.4 Arrhythmias. . . . . . . . . . . . . . . . . . . . . . . . . . . . .2410
4.1.1 Beta-blockers. . . . . . . . . . . . . . . . . . . . . . . . .2395 5.4.1 New-onsetventriculararrhythmiasinthe
4.1.2 Statins. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2398 pre-operativeperiod . . . . . . . . . . . . . . . . . . . . . . . . .2410
4.1.3 Nitrates. . . . . . . . . . . . . . . . . . . . . . . . . . . . .2398 5.4.2 Managementofsupraventriculararrhythmiasand
4.1.4 Angiotensin-convertingenzymeinhibitorsand atrialfibrillationinthepre-operativeperiod. . . . . . . . . . .2410
angiotensin-receptorblockers . . . . . . . . . . . . . . . . . . .2398 5.4.3 Perioperativebradyarrhythmias. . . . . . . . . . . . . .2411
4.1.5 Calciumchannelblockers . . . . . . . . . . . . . . . . .2399 5.4.4 Perioperativemanagementofpatientswith
4.1.6 Alpha receptoragonists. . . . . . . . . . . . . . . . . .2399 pacemaker/implantablecardioverterdefibrillator . . . . . . .2411
2
4.1.7 Diuretics. . . . . . . . . . . . . . . . . . . . . . . . . . . .2399 5.5 Renaldisease . . . . . . . . . . . . . . . . . . . . . . . . . . . .2411
4.2 Perioperativemanagementinpatientsonanti-platelet 5.6 Cerebrovasculardisease. . . . . . . . . . . . . . . . . . . . .2413
agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2400 5.7 Peripheralarterydisease. . . . . . . . . . . . . . . . . . . . .2414
4.2.1 Aspirin . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2400 5.8 Pulmonarydisease. . . . . . . . . . . . . . . . . . . . . . . . .2415
4.2.2 Dualanti-platelettherapy . . . . . . . . . . . . . . . . .2400 5.9 Congenitalheartdisease. . . . . . . . . . . . . . . . . . . . .2416
4.2.3 Reversalofanti-platelettherapy . . . . . . . . . . . . .2401 6. Perioperativemonitoring . . . . . . . . . . . . . . . . . . . . . . . .2416
4.3 Perioperativemanagementinpatientsonanticoagulants. .2401 6.1 Electrocardiography. . . . . . . . . . . . . . . . . . . . . . . .2416
4.3.1 VitaminKantagonists. . . . . . . . . . . . . . . . . . . .2401 6.2 Transoesophagealechocardiography. . . . . . . . . . . . .2417
4.3.2 Non-vitaminKantagonistoralanticoagulants. . . . .2402 6.3 Rightheartcatheterization. . . . . . . . . . . . . . . . . . . .2418
ESC/ESAGuidelines 2385
6.4 Disturbedglucosemetabolism. . . . . . . . . . . . . . . . .2418 ECG electrocardiography/electrocardiographically/electro-
6.5 Anaemia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2419 cardiogram
7. Anaesthesia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2419 eGFR estimatedglomerularfiltrationrate
7.1 Intra-operativeanaestheticmanagement. . . . . . . . . . .2420 ESA EuropeanSocietyofAnaesthesiology
7.2 Neuraxialtechniques. . . . . . . . . . . . . . . . . . . . . . .2420 ESC EuropeanSocietyofCardiology
EVAR endovascularabdominalaorticaneurysmrepair
7.3 Perioperativegoal-directedtherapy. . . . . . . . . . . . . .2420
FEV Forcedexpiratoryvolumein1second
7.4 Riskstratificationaftersurgery . . . . . . . . . . . . . . . . .2421 1
HbA glycosylatedhaemoglobin
7.5 Earlydiagnosisofpost-operativecomplications . . . . . .2421 1c
HF-PEF heartfailurewithpreservedleftventricularejectionfrac-
7.6 Post-operativepainmanagement. . . . . . . . . . . . . . . .2421
tion
8. Gapsinevidence . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2422
HF-REF heartfailurewithreducedleftventricularejectionfrac-
9. Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2422
tion
10. Appendix. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2425
ICD implantablecardioverterdefibrillator
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2425 ICU intensivecareunit
IHD ischaemicheartdisease
Abbreviations and acronyms INR internationalnormalizedratio
IOCM iso-osmolarcontrastmedium
KDIGO KidneyDisease:ImprovingGlobalOutcomes
AAA abdominalaorticaneurysm LMWH lowmolecularweightheparin
ACEI angiotensinconvertingenzymeinhibitor LOCM low-osmolarcontrastmedium
ACS acutecoronarysyndromes LV leftventricular
AF atrialfibrillation LVEF leftventricularejectionfraction
AKI acutekidneyinjury MaVS MetoprololafterVascularSurgery
AKIN AcuteKidneyInjuryNetwork MDRD ModificationofDietinRenalDisease
ARB angiotensinreceptorblocker MET metabolicequivalent
ASA AmericanSocietyofAnesthesiologists MRI magneticresonanceimaging
b.i.d. bisindiem(twicedaily) NHS NationalHealthService
BBSA Beta-BlockerinSpinalAnesthesia NOAC non-vitaminKoralanticoagulant
BMS bare-metalstent NSQIP NationalSurgicalQualityImprovementProgram
BNP B-typenatriureticpeptide NSTE-ACS non-ST-elevationacutecoronarysyndromes
bpm beatsperminute NT-proBNP N-terminalpro-BNP
CABG coronaryarterybypassgraft O2 oxygen
CAD coronaryarterydisease OHS obesityhypoventilationsyndrome
CARP CoronaryArteryRevascularizationProphylaxis OR oddsratio
CAS carotidarterystenting Pgp plateletglycoprotein
CASS CoronaryArterySurgeryStudy PAC pulmonaryarterycatheter
CEA carotidendarterectomy PAD peripheralarterydisease
CHA DS -VASc cardiac failure, hypertension, age ≥75 (doubled), dia- PAH pulmonaryarteryhypertension
2 2
betes, stroke (doubled)-vascular disease, age 65–74 PCC prothrombincomplexconcentrate
andsexcategory(female) PCI percutaneouscoronaryintervention
CI confidenceinterval POBBLE Peri-OperativeBeta-BLockadE
CI-AKI contrast-inducedacutekidneyinjury POISE Peri-OperativeISchemicEvaluation
CKD chronickidneydisease POISE-2 Peri-OperativeISchemicEvaluation2
CKD-EPI ChronicKidneyDiseaseEpidemiologyCollaboration q.d. quaquedie(oncedaily)
C maximumconcentration RIFLE Risk,Injury,Failure,Loss,End-stagerenaldisease
max
CMR cardiovascularmagneticresonance SPECT singlephotonemissioncomputedtomography
COPD chronicobstructivepulmonarydisease SVT supraventriculartachycardia
CPG CommitteeforPracticeGuidelines SYNTAX SynergybetweenPercutaneousCoronaryIntervention
CPX/CPET cardiopulmonaryexercisetest withTAXUSandCardiacSurgery
CRP C-reactiveprotein TAVI transcatheteraorticvalveimplantation
CRT cardiacresynchronizationtherapy TdP torsadesdepointes
CRT-D cardiacresynchronizationtherapydefibrillator TIA transientischaemicattack
CT computedtomography TOE transoesophagealechocardiography
cTnI cardiactroponinI TOD transoesophagealdoppler
cTnT cardiactroponinT TTE transthoracicechocardiography
CVD cardiovasculardisease UFH unfractionatedheparin
CYP3a4 cytochromeP3a4enzyme VATS video-assistedthoracicsurgery
DAPT dualanti-platelettherapy VHD valvularheartdisease
DECREASE DutchEchocardiographicCardiacRiskEvaluationApply- VISION VascularEventsInNoncardiacSurgeryPatientsCohort
ingStressEchocardiography Evaluation
DES drug-elutingstent VKA vitaminKantagonist
DIPOM DIabeticPost-OperativeMortalityandMorbidity VPB ventricularprematurebeat
DSE dobutaminestressechocardiography VT ventriculartachycardia
2386 ESC/ESAGuidelines
1. Preamble recommendation of particular management options were
weighed and graded according to pre-defined scales, as outlined
Guidelinessummarizeandevaluateallavailableevidence,atthetime inTables1and2.
ofthewritingprocess,onaparticularissuewiththeaimofassisting Theexpertsofthewritingandreviewingpanelscompleted’declara-
healthprofessionalsinselectingthebestmanagementstrategiesfor tionsofinterest’formswhichmightbeperceivedasrealorpotential
anindividualpatientwithagivencondition,takingintoaccountthe sourcesofconflictsofinterest.Theseformswerecompiledintoone
impactonoutcome,aswellastherisk–benefitratioofparticular fileandcanbefoundontheESCwebsite(http://www.escardio.org/
diagnosticortherapeuticmeans.Guidelinesandrecommendations guidelines).Anychangesindeclarationsofinterestthatariseduring
shouldhelphealthprofessionalstomakedecisionsintheirdailyprac- the writing period must be notified to the ESC/ESA and updated.
tice; however, the final decisions concerning an individual patient The Task Force received its entire financial support from the ESC
mustbemadebytheresponsiblehealthprofessional(s),inconsult- andESA,withoutanyinvolvementfromthehealthcareindustry.
ationwiththepatientandcaregiverasappropriate. TheESCCPGsupervisesandco-ordinatesthepreparationofnew
Agreatnumberofguidelineshavebeenissuedinrecentyearsbythe guidelines produced by Task Forces, expert groups or consensus
EuropeanSocietyofCardiology(ESC)andtheEuropeanSocietyof panels. The Committee is also responsible for the endorsement
Anaesthesiology(ESA),aswellasbyothersocietiesandorganisations. processoftheseguidelines.TheESCandJointGuidelinesundergo
Becauseoftheirimpactonclinicalpractice,qualitycriteriaforthede- extensive review by the CPG and partner Guidelines Committee
velopment of guidelines have been established in order to make andexternalexperts.Afterappropriaterevisionsitisapprovedby
alldecisionstransparenttotheuser.Therecommendationsforfor- alltheexpertsinvolvedintheTaskForce.Thefinalizeddocument
mulatingandissuingESC/ESAGuidelinescanbefoundontheESC is approved by the CPG/ESA for simultaneous publication in the
web site (http://www.escardio.org/guidelines-surveys/esc-guidelines/ European Heart Journal and joint partner journal, in this instance
about/Pages/rules-writing.aspx).TheseESC/ESAguidelinesrepresent the European Journal of Anaesthesiology. It was developed after
theofficialpositionofthesetwosocietiesonthisgiventopicandare carefulconsideration of the scientific and medical knowledgeand
regularlyupdated. theevidenceavailableatthetimeoftheirdating.
MembersofthisTaskForcewereselectedbytheESCandESAto ThetaskofdevelopingESC/ESAguidelinescoversnotonlythe
representprofessionalsinvolvedwiththemedicalcareofpatients integrationofthemostrecentresearch,butalsothecreationofedu-
withthispathology.Selectedexpertsinthefieldundertookacom- cationaltoolsandimplementationprogrammesfortherecommen-
prehensive review of the published evidence for management dations.Toimplementtheguidelines,condensedpocketversions,
(includingdiagnosis,treatment,preventionandrehabilitation)ofa summaryslides, booklets with essential messages, summary cards
given condition, according to the ESC Committee for Practice for non-specialists, electronic versions for digital applications
Guidelines(CPG)andESAGuidelinesCommitteepolicy.Acritical (smartphonesetc.)areproduced.Theseversionsareabridgedand
evaluation of diagnostic and therapeutic procedures was per- thus, if needed, one should always refer to the full-text version,
formed,includingassessmentoftherisk–benefitratio.Estimates whichisfreelyavailableontheESCandESAwebsites.Thenational
ofexpectedhealthoutcomesforlargerpopulationswereincluded, societiesoftheESCandoftheESAareencouragedtoendorse,trans-
where data exist. The level of evidence and the strength of lateandimplementtheESCguidelines.Implementationprogrammes
Table1 Classesofrecommendations
Classes of
Suggested wording to use
recommendations
Class I Evidence and/or general agreement Is recommended/is
that a given treatment or procedure indicated
Class II
divergence of opinion about the
treatment or procedure.
Class IIa Weight of evidence/opinion is in Should be considered
Class IIb May be considered
established by evidence/opinion.
Class III Evidence or general agreement that Is not recommended
the given treatment or procedure
is not useful/effective, and in some
cases may be harmful.
ESC/ESAGuidelines 2387
areneededbecauseithasbeenshownthattheoutcomeofdisease morbidityarepredominantlyanissueintheadultpopulationunder-
maybefavourablyinfluencedbythethoroughapplicationofclinical goingmajornon-cardiacsurgery.
recommendations. ThemagnitudeoftheprobleminEuropecanbestbeunderstoodin
Surveysandregistriesareneededtoverifythatreal-lifedailyprac- termsof(i)thesizeoftheadultnon-cardiacsurgicalgroupand(ii)the
ticeisinkeepingwithwhatisrecommendedintheguidelines,thus averageriskofcardiaccomplicationsinthiscohort.Unfortunately,
completingtheloopbetweenclinicalresearch,writingofguidelines, systematicdataontheannualnumberandtypeofoperations—and
disseminatingthemandimplementingthemintoclinicalpractice. on patient outcomes—are only available at a national level in 23
HealthprofessionalsareencouragedtotaketheESC/ESAguide- European countries (41%).1 Additionally, data definitions vary, as
lines fully into account when exercising their clinical judgment, as dodataquantityandquality.Arecentmodellingstrategy,basedon
wellasinthedeterminationandtheimplementationofpreventive, worldwide dataavailable in 2004, estimatedthe numberofmajor
diagnosticortherapeuticmedicalstrategies;however,theESC/ESA operations to be at the rate of 4% of the world population per
guidelinesdonot,inanywaywhatsoever,overridetheindividualre- year.1WhenappliedtoEurope,withanoverallpopulationofover
sponsibilityofhealthprofessionalstomakeappropriateandaccurate 500million,thisfiguretranslatesintoacrudeestimateof19million
decisionsinconsiderationoftheconditionofeachpatient’shealth majorproceduresannually.Whilethemajorityoftheseprocedures
and in consultation with that patient and, where appropriate areperformedinpatientswithminimalcardiovascularrisk,30%of
and/ornecessary,thepatient’scaregiver.Itisalsothehealthprofes- patientsundergoextensivesurgicalproceduresinthepresenceof
sional’sresponsibilitytoverifytherulesandregulationsapplicableto cardiovascularcomorbidity;hence,5.7millionproceduresannually
drugsanddevicesatthetimeofprescription. are performed in European patients who present with increased
riskofcardiovascularcomplications.
Worldwide, non-cardiac surgery is associated with an average
Table2 Levelsofevidence overall complication rate of 7–11% and a mortality rate of 0.8–
1.5%, depending on safety precautions.2 Up to 42% of these are
Level of Data derived from multiple randomized causedbycardiaccomplications.3Whenappliedtothepopulation
evidence A clinical trials or meta-analyses.
intheEuropeanUnionmemberstates,thesefigurestranslateinto
Data derived from a single randomized atleast167000cardiaccomplicationsannuallyduetonon-cardiac
Level of
clinical trial or large non-randomized surgicalprocedures,ofwhich19000arelife-threatening.
evidence B
studies.
Consensus of opinion of the experts and/ 2.2 Changeindemographics
Level of
or small studies, retrospective studies,
evidence C
registries. Withinthenext20years,theageingofthepopulationwillhavea
majorimpactonperioperativepatientmanagement.Itisestimated
that elderly people require surgery four times as often than the
restofthepopulation.4InEurope,itisestimatedthatthenumber
2. Introduction ofpatientsundergoingsurgerywillincreaseby25%by2020.Over
thesametimeperiod,theelderlypopulationwillincreaseby50%.
2.1 Themagnitudeoftheproblem Thetotalnumberofsurgicalproceduresmayincreaseevenfaster
because of the rising frequency of interventions with age.5 The
ThepresentGuidelinesfocusonthecardiovascularmanagementof
results of the United States National Hospital Discharge Survey
patientsinwhomheartdiseaseisapotentialsourceofcomplications
show that the number of surgical procedures will increase in
duringnon-cardiacsurgery.Theriskofperioperativecomplications
almostallagegroupsandthatthelargestincreasewilloccurinthe
dependsontheconditionofthepatientbeforesurgery,thepreva-
middle-aged and elderly. Demographics of patients undergoing
lenceofcomorbidities,andtheurgency,magnitude,type,anddur-
surgery show a trend towards an increasing number of elderly
ationofthesurgicalprocedure.
patients and comorbidities.6 Although mortality from cardiac
Morespecifically,cardiaccomplicationscanariseinpatientswith
disease is decreasing in the general population, the prevalence of
documented or asymptomatic ischaemic heart disease (IHD), left
IHD, heart failure, and cardiovascular risk factors—especially dia-
ventricular (LV) dysfunction, valvular heart disease (VHD), and
betes—isincreasing.Amongthesignificantcomorbiditiesinelderly
arrhythmias,whoundergosurgicalproceduresthatareassociated
patients presenting for general surgery, cardiovascular disease
withprolongedhaemodynamicandcardiacstress.Inthecaseofperi-
(CVD)isthemostprevalent.7Ageperse,however,seemstobere-
operativemyocardialischaemia,twomechanismsareimportant:(i)a
sponsible for only a small increase in the risk of complications;
mismatchinthesupply–demandratioofbloodflow,inresponseto
greaterrisksareassociatedwithurgencyandsignificantcardiac,pul-
metabolic demand due to a coronary artery stenosis that may
monary,andrenaldisease;thus,theseconditionsshouldhavegreater
becomeflow-limitingbyperioperativehaemodynamicfluctuations
impactontheevaluationofpatientriskthanagealone.
and (ii) acute coronary syndromes (ACS) due to stress-induced
ruptureofavulnerableatheroscleroticplaqueincombinationwith
2.3 Purposeandorganization
vascularinflammationandalteredvasomotion,aswellashaemosta-
sis.LVdysfunctionandarrhythmiasmayoccurforvariousreasonsat These Guidelines are intended for physicians and collaborators
allages.BecausetheprevalenceofnotonlyIHDbutalsoVHDand involvedinthepre-operative,operative,andpost-operativecareof
arrhythmiasincreaseswithage,perioperativecardiacmortalityand patientsundergoingnon-cardiacsurgery.
2388 ESC/ESAGuidelines
Table3 Surgicalriskestimateaccordingtotypeofsurgeryorinterventiona,b
CAS¼carotidarterystenting;CEA¼carotidendarterectomy.
aSurgicalriskestimateisabroadapproximationof30-dayriskofcardiovasculardeathandmyocardialinfarctionthattakesintoaccountonlythespecificsurgicalintervention,without
consideringthepatient’scomorbidities.
bAdaptedfromGlanceetal.11
Theobjectiveistoendorseastandardizedandevidence-basedap- bothbegantheprocessofrevisingtheirrespectiveguidelinesconcur-
proachtoperioperativecardiacmanagement.TheGuidelinesrecom- rently.Therespectivewritingcommitteesindependentlyperformed
mend a practical, stepwise evaluation of the patient that integrates theirliteraturereviewandanalysis,andthendevelopedtheirrecom-
clinical risk factors and test results with the estimated stress of the mendations.Oncepeerreviewofbothguidelineswascompleted,the
planned surgical procedure. This results in an individualized cardiac writingcommitteeschosetodiscusstheirrespectiverecommenda-
riskassessment,withtheopportunityofinitiatingmedicaltherapy,cor- tionsregardingbeta-blockertherapyandotherrelevantissues.Any
onaryinterventions,andspecificsurgicalandanaesthetictechniquesin differencesinrecommendationswerediscussedandclearlyarticu-
ordertooptimizethepatient’sperioperativecondition. lated in the text; however, the writing committees aligned a few
Comparedwiththenon-surgicalsetting,datafrom randomized recommendationstoavoidconfusionwithintheclinicalcommunity,
clinicaltrials—whichprovidetheidealevidence-basefortheguide- exceptwhereinternationalpracticevariationwasprevalent.
lines—aresparse.Consequently,whennotrialsareavailableona Following the development and introduction of perioperative
specific cardiac-management regimen in the surgical setting, data cardiac guidelines, their effect on outcome should be monitored.
fromthe non-surgicalsettingareextrapolatedandsimilarrecom- Theobjectiveevaluationofchangesinoutcomewillformanessential
mendationsmade,butwithdifferentlevelsofevidence.Anaesthesiol- partoffutureperioperativeguidelinedevelopment.
ogists,whoareexpertson the specificdemands oftheproposed
surgicalprocedure,willusuallyco-ordinatethepre-operativeevalu-
Recommendationsonpre-operativeevaluation
ation.Themajorityofpatientswithstableheartdiseasecanundergo
lowandintermediate-risksurgery(Table3)withoutadditionalevalu-
ation.Selectedpatientsrequireevaluationbyateamofintegrated
Recommendations Classa Levelb Ref.c
multidisciplinary specialists including anaesthesiologists, cardiolo-
gists,andsurgeonsand,whenappropriate,anextendedteam(e.g.
Selected patients with cardiac
internists, intensivists, pulmonologists or geriatricians).8 Selected
disease undergoing low-and
patients include those identified by the anaesthesiologist because
intermediate-risk non-cardiac
of suspected or known cardiac disease with sufficient complexity surgery may be referred by IIb C
tocarryapotentialperioperativerisk(e.g.congenitalheartdisease, the anaesthesiologist for
unstable symptoms or low functional capacity), patients in whom cardiological evaluation and
medical optimization.
pre-operativemedicaloptimizationisexpectedtoreduceperiopera-
A multidisciplinary expert
tiveriskbeforelow-andintermediate-risksurgery,andpatientswith
team should be considered for
knownorhighriskofcardiacdiseasewhoareundergoinghigh-risk
pre-operative evaluation of
surgery. Guidelines have the potential to improve post-operative patients with known or high IIa C 8
outcomesandhighlighttheexistenceofaclearopportunityforim- risk of cardiac disease
provingthequalityofcareinthishigh-riskgroupofpatients.Inadd- undergoing high-risk non-
cardiac surgery.
ition to promoting an improvement in immediate perioperative
care,guidelinesshouldprovidelong-termadvice.
Becauseoftheavailabilityofnewevidenceandtheinternational aClassofrecommendation.
bLevelofevidence.
impactofthecontroversyovertheDECREASEtrials,theESC/ESA
cReference(s)supportingrecommendations.
and American Collegeof Cardiology/American Heart Association
ESC/ESAGuidelines 2389
3. Pre-operative evaluation wherethelifeexpectancyofthepatientandtheriskoftheoper-
ationareimportantfactorsinevaluatingthepotentialbenefitofthe
3.1 Surgicalriskforcardiacevents surgicalintervention.
Cardiac complications after non-cardiac surgery depend on
patient-relatedriskfactors,onthetypeofsurgery,andonthecir- 3.2 Typeofsurgery
cumstancesunderwhichittakesplace.9Surgicalfactorsthatinflu- Ingeneral,endoscopicandendovasculartechniquesspeedrecovery,
ence cardiac risk are related to the urgency, invasiveness, type, decrease hospital stay, and reduce the rate of complications.12
anddurationoftheprocedure,aswellasthechangeinbodycore However, randomized clinical trials comparing laparoscopic with
temperature,bloodloss,andfluidshifts.5Everyoperationelicitsa open techniques exclude older, sicker, and ’urgent’ patients, and
stress response. This response is initiated by tissue injury and results from an expert-based randomized trial (laparoscopic vs.
mediatedbyneuro-endocrinefactors,andmayinducesympatho- open cholecystectomy) have shown no significant differences in
vagalimbalance.Fluidshiftsintheperioperativeperiodaddtothe conversion rate, pain, complications, length of hospital stay, or
surgical stress. This stress increases myocardial oxygen demand. re-admissions.13
Surgeryalsocausesalterationsinthebalancebetweenprothrom- Thewidevarietyofsurgicalprocedures,inamyriadofdifferent
boticandfibrinolyticfactors,potentiallyresultinginincreasedcor- contexts, makes difficult the assignation of a specific risk of a
onary thrombogenicity. The extent of such changes is majoradversecardiaceventtoeachprocedure.Whenalternative
proportionate to the extent and duration of the intervention. methodstoclassicalopensurgeryareconsidered,eitherthrough
These factors, together with patient position, temperature endovascular or less-invasive endoscopic procedures, the
management,bleeding,andtypeofanaesthesia,maycontributeto potential trade-offs between early benefits due to reduced
haemodynamic derangements, leading to myocardial ischaemia morbidityand mid- to long-term efficacy need to be taken into
andheartfailure.General,locoregional,andneuraxialanaesthesia account.
differ in terms of the stress response evoked by surgery. Less
invasive anaesthetic techniques may reduce early mortality in 3.2.1 Endovascularvs.openvascularprocedures
patients at intermediate-to-high cardiac risk and limit post- Vascularinterventionsareofspecificinterest,notonlybecausethey
operative complications.10 Although patient-specific factors are carrythehighestriskofcardiaccomplications,butalsobecauseof
more important than surgery-specific factors in predicting the themanystudiesthathaveshownthatthisrisk canbe influenced
cardiac risk for non-cardiac surgical procedures, the type of by adequate perioperative measures in these patients.14 Open
surgerycannotbeignored.9 aorticandinfra-inguinalproceduresmustbothberegardedashigh-
Withregardtocardiacrisk,surgicalinterventions—whichinclude riskprocedures.Althoughitisaless-extensiveintervention,infra-
open or endovascular procedures—can be broadly divided into inguinalrevascularizationentailsacardiacrisksimilarto—oreven
low-risk, intermediate-risk, and high-risk groups, with estimated higher than—that of aortic procedures. This can be explained
30-daycardiaceventrates(cardiacdeathandmyocardialinfarction) by the higher incidence of diabetes, renal dysfunction, IHD, and
of,1%,1–5%,and.5%,respectively(Table3). advancedageinthispatientgroup.Thisalsoexplainswhytherisk
Theneedfor,andvalueof,pre-operativecardiacevaluationwill relatedtoperipheralarteryangioplasties,whichareminimallyinva-
alsodependontheurgencyofsurgery.Inthecaseofemergencysur- siveprocedures,isnotnegligible.
gicalprocedures,suchasthoseforrupturedabdominalaorticaneur- Endovascular AAA repair (EVAR) has been associated with
ysm (AAA), major trauma, or for a perforated viscus, cardiac loweroperativemortalityandmorbiditythanopenrepairbutthis
evaluationwillnotalterthecourseorresultoftheinterventionbut advantage reduces with time, due to more frequent graft-related
mayinfluencemanagementintheimmediateperioperativeperiod. complications and re-interventions in patients who underwent
In non-emergency but urgent surgical conditions, such as bypass EVAR, resulting in similar long-term AAA-related mortality and
foracutelimbischaemiaortreatmentofbowelobstruction,themor- totalmortality.15–17
bidityandmortalityoftheuntreatedunderlyingconditionmayout- A meta-analysis of studies, comparing open surgical with
weighthepotentialcardiacriskrelatedtotheintervention.Inthese percutaneoustransluminalmethodsforthetreatmentoffemoro-
cases,cardiologicalevaluationmayinfluencetheperioperativemea- poplitealarterialdisease,showedthatbypasssurgeryisassociated
surestakentoreducecardiacriskbutwillnotinfluencethedecision with higher 30-day morbidity [odds ratio (OR) 2.93; 95%
toperformtheintervention.Insomecases,thecardiacriskcanalso confidence interval (CI) 1.34–6.41] and lower technical failure
influencethetypeofoperationandguidethechoicetoless-invasive thanendovasculartreatment,withnodifferencesin30-daymor-
interventions, suchas peripheral arterialangioplasty instead ofin- tality; however, there were higher amputation-free and overall
fra-inguinal bypass, or extra-anatomical reconstruction instead of survivalratesinthebypassgroupat4years.18Therefore,multiple
an aortic procedure, even when these may yield less favourable factors must be taken into consideration when deciding which
resultsinthelongterm.Finally,insomesituations,thecardiacevalu- typeofprocedureservesthepatientbest.Anendovascular-firstap-
ation(inasfarasitcanreliablypredictperioperativecardiaccompli- proachmaybe advisableinpatientswithsignificant comorbidity,
cationsandlatesurvival)shouldbetakenintoconsiderationwhen whereasabypassproceduremaybeofferedasafirst-lineinterven-
decidingwhethertoperformaninterventionormanageconserva- tional treatment for fit patients with a longer life expectancy.19
tively.Thisisthecaseincertainprophylacticinterventions,suchas Carotidarterystentinghasappearedasanattractive,less-invasive
the treatment of small AAAs orasymptomatic carotid stenosis, alternative to CEA; however, although CAS reduces the rate of
2390 ESC/ESAGuidelines
periprocedural myocardial infarction and cranial nerve palsy, the
Recommendationsontheselectionofsurgicalapproach
combined 30-day rate of stroke or death is higher than CEA,
anditsimpactonrisk
particularlyinsymptomaticandolderpatients,drivenbyadiffer-
ence in the risk of periprocedural non-disabling stroke.20,21
The benefit of carotid revascularization is particularly high in Recommendations Classa Levelb Ref.c
patients with recent (,3 months) transient ischaemic attack
(TIA)orstrokeanda.60%carotidarterybifurcationstenosis.22 It is recommended that patients
Inneurologicallyasymptomaticpatients,carotidrevascularization should undergo pre-operative risk
26,27,
benefit is questionable, compared with modern medical assessment independently of an I C
35
open or laparoscopic surgical
therapy,except inpatients witha .80%carotid stenosis and an
approach.d
estimated life expectancy of .5 years.21 The choice between
In patients with AAA 55 mm,
CEA and CAS must integrate operator experience and results,
anatomically suited for EVAR,
anatomical characteristics of the arch vessels, neck features, and
either open or endovascular aortic I A 15–17
comorbidities.21–23
repair is recommended if surgical
risk is acceptable.
In patients with asymptomatic
3.2.2 Openvs.laparoscopicorthoracoscopic AAA who are unfit for open
procedures repair, EVAR,along with best IIb B 15,35
Laparoscopic procedures, compared with open procedures, have medical treatment,may be
theadvantageofcausinglesstissuetraumaandintestinalparalysis, considered.
resulting in less incisional pain, better post-operative pulmonary In patients with lower extremity
function,significantlyfewerwallcomplications,anddiminishedpost- artery disease requiring
operativefluidshiftsrelatedtobowelparalysis.24However,thepneu- revascularization, the best
management strategy should be
moperitoneum required for these procedures results in elevated IIa B 18
determined by an expert team
intra-abdominalpressureandareductioninvenousreturn.Typical considering anatomy,
physiological sequelae are secondary to increased intra-abdominal comorbidities, local availability, and
pressureandabsorptionofthegaseousmediumusedforinsufflation. expertise.
Whilehealthyindividualsoncontrolledventilationtypicallytolerate
pneumoperitoneum, debilitated patients with cardiopulmonary AAA¼abdominalaorticaneurysm;EVAR¼endovascularaorticreconstruction.
compromise and obese patients may experience adverse conse- aClassofrecommendation.
quences.25PneumoperitoneumandTrendelenburgpositionresult bLevelofevidence.
cReference(s)supportingrecommendations.
inincreasedmeanarterialpressure,centralvenouspressure,mean dSincelaparoscopicproceduresdemonstrateacardiacstresssimilartothatofopen
pulmonaryartery,pulmonarycapillarywedgepressure,andsystemic procedures.
vascularresistanceimpairingcardiacfunction.26,27Therefore,com-
paredwithopensurgery,cardiacriskinpatientswithheartfailure
isnotreducedinpatientsundergoinglaparoscopy,andbothshould
3.3 Functionalcapacity
beevaluatedinthesameway.Thisisespeciallytrueinpatientsunder-
going interventions for morbid obesity, but also in other types of Determination of functional capacity is a pivotal step in pre-
surgery, considering the risk of conversion to an open proced- operative cardiac risk assessment and is measured in metabolic
ure.28,29 Superior short-term outcomes of laparoscopic vs. open equivalents(METs).OneMETequalsthebasalmetabolicrate.Ex-
procedureshavebeenreported,dependingontypeofsurgery,oper- ercisetestingprovidesanobjectiveassessmentoffunctionalcap-
atorexperienceandhospitalvolume,butfewstudiesprovidedirect acity.Withouttesting,functionalcapacitycanbeestimatedfrom
measuresofcardiaccomplications.30–32Benefitfromlaparoscopic theabilitytoperformtheactivitiesofdailyliving.OneMETrepre-
procedures is probably greater in elderly patients, with reduced sents metabolic demand at rest; climbing two flights of stairs
lengthofhospitalstay,intra-operativebloodloss,incidenceofpost- demands4METs,andstrenuoussports,suchasswimming, .10
operativepneumonia,timetoreturnofnormalbowelfunction,in- METS(Figure1).
cidenceofpost-operativecardiaccomplications,andwoundinfec- Theinabilitytoclimbtwoflightsofstairsorrunashortdistance
tions.33Fewdataareavailableforvideo-assistedthoracicsurgery (,4 METs) indicates poor functional capacity and is associated
(VATS), with no large, randomized trial comparing VATS with withanincreasedincidenceofpost-operativecardiacevents.After
open thoracic lung resection. In one study involving propensity- thoracic surgery, a poor functional capacity has been associated
score-matchedpatients,VATSlobectomywasassociatedwithno with an increased mortality (relative risk 18.7; 95% CI 5.9–59);
significant difference in mortality, but with significantly lower however, in comparison with thoracic surgery, a poor functional
rates of overall perioperative morbidity, pneumonia, and atrial statuswasnotassociatedwithanincreasedmortalityafterothernon-
arrhythmia.34 cardiac surgery (relative risk 0.47; 95% CI 0.09–2.5).38 This may
ESC/ESAGuidelines 2391
and then extended, if indicated, to resting electrocardiography
(ECG),laboratorymeasurements,orothernon-invasiveassessments.
Functional capacity Severalriskindiceshavebeendevelopedduringthepast30years,
based on multivariate analyses of observational data, which
1 MET Can you... 4 METs Can you... representtherelationshipbetweenclinicalcharacteristicsandperi-
operative cardiac mortality and morbidity. The indices developed
Take care of yourself? Climb two flights of stairs
Eat, dress, or walk up a hill? by Goldman et al. (1977),41 Detsky et al. (1986),42 and Lee et al.
or use the toilet?
Do heavy work (1999)43havebecomewell-known.
Walk indoors around the house like Although only a rough estimation, the older risk-stratification
around scrubbing floors of lifting
the house? or moving heavy systemsmayrepresentusefulclinicaltoolsforphysiciansinrespect
furniture?
oftheneedforcardiacevaluation,drugtreatment,andassessment
Walk 100 m Participate in strenuous
on level ground sports like swimming, of risk for cardiac events. The Lee index or ‘revised cardiac risk’
at 3 to 5 km per h? singles tennis, football, index,amodifiedversionoftheoriginalGoldmanindex,wasdesigned
basketball, or skiing?
topredictpost-operativemyocardialinfarction,pulmonaryoedema,
4 METs
ventricularfibrillationorcardiacarrest,andcompleteheartblock.
Greater than 10 METs This risk index comprises six variables: type of surgery, history
ofIHD,historyofheartfailure,historyofcerebrovasculardisease,
pre-operativetreatmentwithinsulin,andpre-operativecreatinine
Figure1 Estimatedenergyrequirementsforvariousactivities. .170mmol/L(.2mg/dL),andusedtobeconsideredbymanyclin-
BasedonHlatkyetal.andFletcheretal.36,37kmperh¼kilometres iciansandresearcherstobethebestcurrentlyavailablecardiac-risk
perhour;MET¼metabolicequivalent. predictionindexinnon-cardiacsurgery.
Alloftheabove-mentionedriskindiceswere,however,developed
yearsagoandmanychangeshavesinceoccurredinthetreatmentof
IHDandintheanaesthetic,operativeandperioperativemanagement
ofnon-cardiacsurgicalpatients.Anewpredictivemodelwasrecently
reflecttheimportanceofpulmonaryfunction—stronglyrelatedto
developedtoassesstheriskofintra-operative/post-operativemyo-
functionalcapacity—asamajorpredictorofsurvivalafterthoracic
cardialinfarctionorcardiacarrest,usingtheAmericanCollegeofSur-
surgery.Thesefindingswereconfirmedinastudyof5939patients
geons National Surgical Quality Improvement Program (NSQIP)
scheduledfornon-cardiacsurgery,inwhichthepre-operativefunc-
database.44 This NSQIP MICA model was built on the 2007 data
tionalcapacitymeasuredinMETsshowedarelativelyweakassoci-
ationwithpost-operativecardiaceventsordeath.39Notably,when set, based on patients from 180 hospitals, and was validated with
the2008dataset,bothcontaining.200000patientsandhavingpre-
functionalcapacityishigh,theprognosisisexcellent,eveninthepres-
enceofstableIHDorriskfactors;40otherwise,whenfunctionalcap- dictability.Theprimaryendpointwasintra-operative/post-operative
myocardialinfarctionorcardiacarrestupto30daysaftersurgery.
acityispoororunknown,thepresenceandnumberofriskfactorsin
Five predictors of perioperative myocardial infarction/cardiac
relationtotheriskofsurgerywilldeterminepre-operativeriskstrati-
arrestwereidentified:typeofsurgery,functionalstatus,elevatedcre-
ficationandperioperativemanagement.
atinine (.130mmol/L or .1.5mg/dL), American Society of
Anesthesiologists(ASA)class(ClassI,patientiscompletelyhealthy;
3.4 Riskindices
Class II, patient has mild systemic disease; Class III, patient has
For two main reasons, effective strategies aimed at reducing the severe systemic disease that is not incapacitating; Class IV, patient
risk of perioperative cardiac complications should involve cardiac hasincapacitatingdiseasethatisaconstantthreattolife;andClass
evaluation, using medical history before the surgical procedure,. V, a moribund patient who is not expected to live for 24 hours,
Firstly,patientswithananticipatedlowcardiacrisk—afterthorough withorwithoutthesurgery),andage.Thismodelispresentedas
evaluation—can be operated on safely without further delay. It is an interactive risk calculator (http://www.surgicalriskcalculator.
unlikely that risk-reduction strategies will further reduce the com/miorcardiacarrest) so that the risk can be calculated at the
perioperativerisk.Secondly,riskreductionbypharmacologicaltreat- bedside or clinic in a simple and accurate way. Unlike other risk
mentismostcost-effectiveinpatientswithasuspectedincreased scores,theNSQIPmodeldidnotestablishascoringsystembutpro-
cardiacrisk.Additionalnon-invasivecardiacimagingtechniquesare videsamodel-basedestimateoftheprobabilityofmyocardialinfarc-
toolstoidentifypatientsathigherrisk;however,imagingtechniques tion/cardiac arrest for an individual patient. The risk calculator
shouldbereservedforthosepatientsinwhomtestresultswouldin- performedbetterthantheLeeriskindex,withsomereductionin
fluenceandchangemanagement.Clearly,theintensityofthepre- performance in vascular patients, although it was still superior;
operativecardiacevaluationmustbetailoredtothepatient’sclinical however, some perioperative cardiac complications of interest to
conditionandtheurgencyofthecircumstancesrequiringsurgery. clinicians, such as pulmonary oedema and complete heart block,
Whenemergencysurgeryisneeded,theevaluationmustnecessarily werenotconsideredintheNSQIPmodelbecausethosevariables
belimited;however,mostclinicalcircumstancesallowtheapplication were not included in the NSQIP database. By contrast, the Lee
ofamoreextensive,systematicapproach,withcardiacriskevaluation index allows estimation of the risk of perioperative pulmonary
thatisinitiallybasedonclinicalcharacteristicsandtypeofsurgery oedema and of complete heart block, in addition to death and
2392 ESC/ESAGuidelines
myocardialinfarction(http://www.mdcalc.com/revised-cardiac-risk-
index-for-pre-operative-risk/). A recent systematic review of 24 Recommendations Classa Levelb Ref.c
studiescovering.790000patientsfoundthattheLeeindexdiscri-
Clinical risk indices are
minated moderately well patients at low vs. high risk for cardiac recommended to be used
events after mixed non-cardiac surgery, but its performance was for peri-operative risk I B 43,44
hamperedwhenpredictingcardiaceventsaftervascularnon-cardiac stratification.
surgeryorpredictingdeath.45 Therefore,theNSQIPandLeerisk The NSQIP model or the
indexmodelsprovidecomplementaryprognosticperspectivesand Lee risk index are
canhelptheclinicianinthedecision-makingprocess. recommended for cardiac I B 43,44,54
Riskmodelsdonotdictatemanagementdecisionsbutshouldbe peri-operative risk
stratification.
regarded as one piece of the puzzle to be evaluated, in concert
withthemoretraditionalinformationatthephysician’sdisposal. Assessment of cardiac
troponins in high-risk
3.5 Biomarkers patients, both before and
IIb B 3,48,49
48–72 hours after major
Abiologicalmarker,or’biomarker’,isacharacteristicthatcanbeob-
surgery, may be
jectivelymeasuredandwhichisanindicatorofbiologicalprocesses. considered.
Intheperioperativesetting,biomarkerscanbedividedintomarkers
NT-proBNP and BNP
focusingonmyocardialischaemiaanddamage,inflammation,andLV
measurements may be
function.CardiactroponinsTandI(cTnTandcTnI,respectively)are considered for obtaining
the preferred markers for the diagnosis of myocardial infarction independent prognostic
IIb B 52,53,55
because they demonstrate sensitivity and tissue specificity better information for peri-
thanotheravailablebiomarkers.46Theprognosticinformationisin- operative and late cardiac
events in high-risk
dependent of—and complementary to—other important cardiac
patients.
indicators of risk, such as ST deviation and LV function. It seems
thatcTnIandcTnTareofsimilarvalueforriskassessmentinACS Universal pre-operative
routine biomarker
inthepresenceandabsenceofrenalfailure.Existingevidencesug-
sampling for risk
geststhatevensmallincreasesincTnTintheperioperativeperiod III C
stratification and to
reflect clinically relevant myocardial injury with worsened cardiac
prevent cardiac events is
prognosisandoutcome.47–49Thedevelopmentofnewbiomarkers, not recommended.
includinghigh-sensitivitytroponins,willprobablyfurtherenhancethe
assessmentofmyocardialdamage.48Assessmentofcardiactropo-
BNP¼B-typenatriureticpeptide;NT-proBNP¼N-terminalpro-brainnatriuretic
ninsinhigh-riskpatients,bothbeforeand48–72hoursaftermajor
peptide.
surgery,maythereforebeconsidered.3Itshouldbenotedthattropo- NSQIP ¼ NationalSurgicalQualityImprovementProgram.
ninelevationmayalsobeobservedinmanyotherconditions;the aClassofrecommendation.
bLevelofevidence.
diagnosis of non-ST-segment elevation myocardial infarction cReference(s)supportingrecommendations.
shouldneverbemadesolelyonthebasisofbiomarkers.
Inflammatory markers might pre-operatively identify those
patients with an increased risk of unstable coronary plaque;
however,inthesurgicalsetting,nodataarecurrentlyavailableon
howinflammatorymarkerswouldalterrisk-reductionstrategies.
B-type natriuretic peptide (BNP) and N-terminal pro-BNP
3.6 Non-invasivetesting
(NT-proBNP) are produced in cardiac myocytes in response to
increasesinmyocardialwallstress.Thismayoccuratanystageof Pre-operativenon-invasivetestingaimstoprovideinformationon
heartfailure,independentlyofthepresenceorabsenceofmyocardial three cardiac risk markers: LV dysfunction, myocardial ischaemia,
ischaemia.PlasmaBNPandNT-proBNPhaveemergedasimportant andheartvalveabnormalities,allofwhicharemajordeterminants
prognosticindicatorsacrossmanycardiacdiseasesinnon-surgical ofadversepost-operativeoutcome.LVfunctionisassessedatrest,
settings.50Pre-operativeBNPandNT-proBNPlevelshaveadditional andvariousimagingmethodsareavailable.Fordetectionofmyocar-
prognosticvalueforlong-termmortalityandforcardiaceventsafter dial ischaemia, exercise ECG and non-invasive imaging techniques
majornon-cardiacvascularsurgery.51–53 may be used. Routine chest X-ray before non-cardiac surgery is
Data from prospective, controlled trials on the use of pre- notrecommendedwithoutspecificindications.Theoveralltheme
operativebiomarkersaresparse.Basedontheexistingdata,assess- isthatthediagnosticalgorithmforriskstratificationofmyocardialis-
ment of serum biomarkers for patients undergoing non-cardiac chaemia and LV function should be similar to that proposed for
surgerycannotbeproposedforroutineuse,butmaybeconsidered patients in the non-surgical setting with known or suspected
inhigh-riskpatients(METs ≤4orwitharevisedcardiacriskindex IHD.56Non-invasivetestingshouldbeconsiderednotonlyforcor-
value.1forvascularsurgeryand.2fornon-vascularsurgery). onary artery revascularization but also for patient counselling,
Recommendationsoncardiacriskstratification changeofperioperativemanagementinrelationtotypeofsurgery,
anaesthetictechnique,andlong-termprognosis.