Guidelines for pre-operative cardiac risk assessment and

44 Pages·2009·1.55 MB·English

ESC GUIDELINES
EuropeanHeartJournal(2009)30,2769–2812
doi:10.1093/eurheartj/ehp337
Guidelines for pre-operative cardiac risk
assessment and perioperative cardiac
management in non-cardiac surgery
The Task Force for Preoperative Cardiac Risk Assessment and
Perioperative Cardiac Management in Non-cardiac Surgery of the
European Society of Cardiology (ESC) and endorsed by the
European Society of Anaesthesiology (ESA)
Authors/Task Force Members: Don Poldermans; (Chairperson) (The Netherlands)*;
Jeroen J. Bax (The Netherlands); Eric Boersma (The Netherlands); Stefan De Hert
(The Netherlands); Erik Eeckhout (Switzerland); Gerry Fowkes (UK);
Bulent Gorenek (Turkey); Michael G. Hennerici (Germany); Bernard Iung (France);
Malte Kelm (Germany); Keld Per Kjeldsen (Denmark); Steen Dalby Kristensen
(Denmark); Jose Lopez-Sendon (Spain); Paolo Pelosi (Italy); Franc¸ois Philippe
(France); Luc Pierard (Belgium); Piotr Ponikowski (Poland); Jean-Paul Schmid
(Switzerland); Olav F.M. Sellevold (Norway); Rosa Sicari (Italy);
Greet Van den Berghe (Belgium); Frank Vermassen (Belgium)
Additional Contributors: Sanne E. Hoeks (The Netherlands);
Ilse Vanhorebeek (Belgium)
ESC Committeefor PracticeGuidelines(CPG): AlecVahanian; (Chairperson)(France);Angelo Auricchio
(Switzerland);JeroenJ.Bax(TheNetherlands);ClaudioCeconi(Italy);VeronicaDean(France);GerasimosFilippatos
(Greece);ChristianFunck-Brentano(France);RichardHobbs(UK);PeterKearney(Ireland);TheresaMcDonagh(UK);
Keith McGregor (France);Bogdan A. Popescu (Romania); Zeljko Reiner(Croatia); Udo Sechtem (Germany);
PerAntonSirnes(Norway); Michal Tendera (Poland);Panos Vardas (Greece);Petr Widimsky (Czech Republic)
Document Reviewers: Raffaele De Caterina; (CPG Review Coordinator) (Italy); Stefan Agewall (Norway);
NawwarAlAttar(France);FelicitaAndreotti(Italy);StefanD.Anker(Germany);GonzaloBaron-Esquivias(Spain);
Guy Berkenboom (Belgium); Laurent Chapoutot (France); Renata Cifkova (Czech Republic); Pompilio Faggiano
(Italy); Simon Gibbs (UK); Henrik Steen Hansen (Denmark); Laurence Iserin (France); Carsten W. Israel
(Germany); Ran Kornowski (Israel); Nekane Murga Eizagaechevarria (Spain); Mauro Pepi (Italy); Massimo Piepoli
(Italy);HansJoachimPriebe(Germany);MartinScherer(Germany);JaninaStepinska(Poland);DavidTaggart(UK);
Marco Tubaro (Italy)
ThedisclosureformsofalltheauthorsandreviewersareavailableontheESCwebsitewww.escardio.org/guidelines
*Correspondingauthor:DonPoldermans,DepartmentofSurgery,ErasmusMedicalCenter,Gravendijkwal230,3015CERotterdam,TheNetherlands.Tel:þ31107034613,
Fax:þ31104364557,Email:[email protected]
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Disclaimer.TheESCGuidelinesrepresenttheviewsoftheESCandwerearrivedataftercarefulconsiderationoftheavailableevidenceatthetimetheywerewritten.Health
professionalsareencouragedtotakethemfullyintoaccountwhenexercisingtheirclinicaljudgement.Theguidelinesdonot,however,over-ridetheindividualresponsibilityof
healthprofessionalstomakeappropriatedecisionsinthecircumstancesoftheindividualpatients,inconsultationwiththatpatient,andwhereappropriateandnecessarythepatient’s
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2770 ESCGuidelines
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Keywords Non-cardiacsurgery † Pre-operativecardiacriskassessment † Pre-operativecardiactesting † Pre-operativecoronary
arteryrevascularization † Perioperativecardiacmanagement † Renal disease † Pulmonary disease † Neurological
disease † Anaesthesiology † Post-operativecardiacsurveillance
AF atrialfibrillation
Table of Contents
BBSA b-blockerinspinalanaesthesia
BNP brainnatriureticpeptide
Listofacronymsandabbreviations. . . . . . . . . . . . . . . . . . . .2770
CABG coronaryarterybypassgrafting
Preamble. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2771
CARP coronaryarteryrevascularizationprophylaxis
Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2771
CASS coronaryarterysurgerystudy
Magnitudeoftheproblem. . . . . . . . . . . . . . . . . . . . . . .2771
CI confidenceinterval
Impactoftheageingpopulation . . . . . . . . . . . . . . . . . . .2773
COX-2 cyclooxygenase-2
Purpose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2773
COPD chronic obstructivepulmonarydisease
Pre-operativeevaluation. . . . . . . . . . . . . . . . . . . . . . . . . . .2774
CPET cardiopulmonaryexercise testing
Surgicalriskforcardiacevents . . . . . . . . . . . . . . . . . . . .2774
CPG Committee forPractice Guidelines
Functionalcapacity. . . . . . . . . . . . . . . . . . . . . . . . . . . .2775
CRP C-reactiveprotein
Riskindices. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2776
CT computed tomography
Biomarkers. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2777
cTnI cardiactroponin I
Non-invasivetesting . . . . . . . . . . . . . . . . . . . . . . . . . . .2777
cTnT cardiactroponin T
Angiography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2780
CVD cardiovascular disease
Riskreductionstrategies. . . . . . . . . . . . . . . . . . . . . . . . . . .2781
DECREASE Dutch Echocardiographic Cardiac Risk Evaluating
Pharmacological. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2781
Applying StressEcho
Revascularization . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2789
DES drug-eluting stent
Specificdiseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2792
DIPOM Diabetes PostoperativeMortalityandMorbidity
Chronicheartfailure . . . . . . . . . . . . . . . . . . . . . . . . . .2792
DSE dobutamine stressechocardiography
Arterialhypertension . . . . . . . . . . . . . . . . . . . . . . . . . .2793
ECG electrocardiography
Valvularheartdisease. . . . . . . . . . . . . . . . . . . . . . . . . .2793
ESC EuropeanSocietyof Cardiology
Arrhythmias . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2794
FEV forcedexpiratory volumein 1s
Renaldisease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2795 1
FRISC fast revascularization in instability in coronary
Cerebrovasculardisease . . . . . . . . . . . . . . . . . . . . . . . .2796
disease
Pulmonarydisease . . . . . . . . . . . . . . . . . . . . . . . . . . . .2797
HR hazard ratio
Perioperativemonitoring . . . . . . . . . . . . . . . . . . . . . . . . . .2799
ICU intensive careunit
Electrocardiography . . . . . . . . . . . . . . . . . . . . . . . . . . .2799
IHD ischaemic heart disease
Transoesophagealechocardiography . . . . . . . . . . . . . . . .2799
INR internationalnormalizedratio
Rightheartcatherization . . . . . . . . . . . . . . . . . . . . . . . .2800
LMWH lowmolecularweightheparin
Disturbedglucosemetabolism . . . . . . . . . . . . . . . . . . . .2801
LQTS long QTsyndrome
Anaesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2802
LR likelihood ratio
Intraoperativeanaestheticmanagement . . . . . . . . . . . . . .2803
LV left ventricular
Neuraxialtechniques . . . . . . . . . . . . . . . . . . . . . . . . . .2803
MaVS metoprolol after surgery
Post-operativepainmanagement. . . . . . . . . . . . . . . . . . .2803
MET metabolic equivalent
Puttingthepuzzletogether. . . . . . . . . . . . . . . . . . . . . . . . .2803
MI myocardial infarction
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2807
MR mitral regurgitation
MRI magnetic resonanceimaging
MS mitral stenosis
List of acronyms and abbreviations
NICE-SUGAR normoglycaemia in intensive care evaluation and
survival using glucosealgorithm regulation
AAA abdominalaorticaneurysm NSTEMI non-ST-segmentelevation myocardial infarction
ACC American College ofCardiology NT-proBNP N-terminal pro-brainnatriureticpeptide
ACE angiotensin-convertingenzyme NYHA NewYorkHeartAssociation
ACS acute coronarysyndrome OPUS orbofiban in patients with unstable coronary
AHA American HeartAssociation syndromes
AR aorticregurgitation OR odds ratio
ARB angiotensinreceptor blocker PaCO2 mixed expired volume of alveolaranddead space
AS aorticstenosis gas
ESCGuidelines 2771
PAH pulmonaryarterialhypertension evidence and the strength of recommendation of particular
PETCO end-tidal expiratoryCO pressure treatment options are weighted and graded according to pre-
2 2
PCI percutaneouscoronary intervention defined scales,asoutlinedinTables1 and 2.
PDA personaldigitalassistant The experts of the writing panels have provided disclosure
POISE PeriOperativeISchaemic Evaluationtrial statementsofallrelationshipstheymayhavewhichmightbeper-
QUO-VADIS QUinapril On Vascular ACE and Determinants of ceived as real or potential sources of conflicts of interest. These
ISchemia disclosure forms are kept on file at the European Heart House,
ROC receiveroperatingcharacteristic headquarters of the ESC. Any changes in conflict of interest that
SD standard deviation arise during the writing period must be notified to the ESC. The
SMVT sustained monomorphicventricular tachycardia Task Force report is entirely supported financially by the ESC
SPECT singlephoton emissioncomputed tomography without anyinvolvement ofindustry.
SPVT sustained polymorphicventricular tachycardia The ESC Committee for Practice Guidelines (CPG) supervises
STEMI ST-segment elevationmyocardial infarction and coordinates the preparation of new Guidelines and Expert
SVT supraventricular tachycardia Consensus Documents produced by Task Forces, expert groups,
SYNTAX synergybetweenpercutaneouscoronaryinterven- or consensus panels. The Committee is also responsible for the
tionwithtaxusandcardiacsurgery endorsement process of these Guidelines and Expert Consensus
TACTICS treat angina with aggrastat and determine cost of Documentsorstatements.Oncethedocumenthasbeenfinalized
therapywith aninvasive orconservativestrategy and approved by all the experts involved in the Task Force, it is
TIA transient ischaemic attack submitted to outside specialists for review. The document is
TIMI thrombolysisinmyocardial infarction revised, and finally approved by the CPG and subsequently
TOE transoesophagealechocardiography published.
UFH unfractionatedheparin Afterpublication,disseminationofthemessageisofparamount
VCO carbondioxide production importance. Pocketsize versions and personal digital assistant
2
VE minuteventilation (PDA)-downloadable versions are useful at the point of care.
VHD valvularheart disease Somesurveyshaveshownthattheintendedend-usersaresome-
VKA vitamin Kantagonist times not aware of the existence of guidelines, or simply do not
VO oxygenconsumption translate them into practice, so this is why implementation pro-
2
VPB ventricularprematurebeat grammes for new guidelines form an important component of
VT ventriculartachycardia the dissemination of knowledge. Meetings are organized by the
ESC, and are directed towards its member National Societies
and key opinion leaders in Europe. Implementation meetings can
Preamble also be undertaken at national levels, once the guidelines have
been endorsed by the ESC member societies, and translatedinto
GuidelinesandExpertConsensusDocumentsaimtopresentman- the national language. Implementation programmes are needed
agementandrecommendationsbasedontherelevantevidenceon because it has been shown that the outcome of disease may be
a particular subject in order to help physicians to select the best favourably influenced by the thorough application of clinical
possiblemanagementstrategiesfortheindividualpatientsuffering recommendations.2
fromaspecificcondition,takingintoaccountnotonlytheimpact Thus,thetaskofwritingGuidelinesorExpertConsensusDocu-
onoutcome,butalsotherisk–benefitratioofparticulardiagnostic mentscoversnotonlytheintegrationofthemostrecentresearch,
ortherapeuticmeans.Guidelinesarenosubstitutesfortextbooks. butalsothecreationofeducationaltoolsandimplementationpro-
The legal implications of medical guidelines have been discussed grammes for the recommendations. The development of clinical
previously.1 guidelines and implementation into clinical practice can then only
A great number of Guidelines and Expert Consensus Docu- be completed if surveys and registries are performed to verify its
ments have been issued in recent years by the European Society use in real-life daily practices. Such surveys and registries also
of Cardiology (ESC) and also by other organizations or related make it possible to evaluate the impact of implementation of the
societies.Becauseoftheimpactonclinicalpractice,qualitycriteria guidelinesonpatientoutcomes.Guidelinesandrecommendations
for development of guidelines have been established in order to should help physicians and other healthcare providers to make
makealldecisionstransparenttotheuser.Therecommendations decisions in their daily practice. However, the physician in charge
for formulating and issuing ESC guidelines and Expert Consensus of his/her care must make the ultimate judgement regarding the
Documents can be found on the ESC website in the guidelines careofanindividual patient.
section (www.escardio.org).
In brief,expertsinthefield are selectedandundertakeacom-
Introduction
prehensivereviewofthepublishedevidenceformanagementand/
orpreventionofagivencondition.Acriticalevaluationofdiagnos-
Magnitude of the problem
ticandtherapeuticproceduresisperformed,includingassessment
of the risk–benefit ratio. Estimates of expected health outcomes The present guidelines focus on the cardiological management of
for larger societies are included, where data exist. The level of patientsundergoing non-cardiac surgery,i.e. patients where heart
2772 ESCGuidelines
Table1 Classesofrecommendations
Table2 Levelofevidence
disease is a potentialsourceofcomplicationsduringsurgery.The The magnitude of the problem in Europe can best be under-
risk of perioperative complications depends on the condition of stood in terms of (i) the size of the adult non-cardiac surgical
the patient prior to surgery, the prevalence of co-morbidities, cohort; and (ii) the average risk of cardiac complications within
and the magnitude and duration of the surgical procedure.3 this cohort. Unfortunately, at a European level, no systematic
More specifically, cardiac complications can arise in patients with data are available on the annual number and type of operations,
documented or asymptomatic ischaemic heart disease (IHD), left nor on patient outcome. Information is collected at the national
ventricular (LV) dysfunction, and valvular heart disease (VHD) level in several countries, but data definitions, amount of data,
who undergo procedures that are associated with prolonged anddataqualityvarygreatly.InTheNetherlands,withapopulation
haemodynamic and cardiac stress. In the case of perioperative of16million,throughout1991–2005,250000majorsurgicalpro-
myocardial ischaemia, two mechanisms are important: (i) chronic cedureswereconductedonaverageannuallyinpatientsabovethe
mismatch in the supply-to-demand ratio of blood flow response ageof20years,implyinganannualrateof1.5%.4Whenappliedto
to metabolic demand, which clinically resembles stable IHD due Europe,withanoverallpopulationof490million,thisfiguretrans-
toaflowlimitingstenosisincoronaryconduitarteries;and(ii)cor- latesintoacrudeestimateof7millionmajorproceduresannually
onaryplaqueruptureduetovascularinflammatoryprocessespre- inpatientswhopresentwith cardiac risk.
sentingasacutecoronarysyndromes(ACSs).Hence,althoughLV Data on cardiac outcome can be derived from the few
dysfunctionmayoccurforvariousreasonsinyoungeragegroups, large-scale clinical trials and registries that have been undertaken
perioperative cardiac mortality and morbidity are predominantly in patients undergoing non-cardiac surgery. Lee et al. studied
an issue in the adult population undergoing major non-cardiac 4315 patients undergoing elective major non-cardiac procedures
surgery. in atertiary careteaching hospital throughout1989–1994.5 They
ESCGuidelines 2773
observed that 92 (2.1%) patients suffered major cardiac compli-
Table3 Changeinnumbersofdischargesforsurgical
cations, including cardiac death and myocardial infarction (MI). In
proceduresbyageforthetimeperiods1994/95and
a cohort of 108 593 consecutive patients who underwent
2004/05asreportedfromthe2005USNational
surgery throughout 1991–2000 in a university hospital in The
HospitalDischargeSurvey(non-federalshort-stay
Netherlands, perioperative mortality occurred in 1877 (1.7%)
hospitals)15
patients, with a cardiovascular cause being identified in 543 cases
(0.5%).6 The Dutch Echocardiographic Cardiac Risk Evaluating
Age(years) Numberofprocedures %change
Applying Stress Echo (DECREASE) -I, -II and -IV trials enrolled (inthousands)
...............................
3893 surgical patients throughout 1996–2008, and these com-
1994/95 2004/05
prised intermediate- and high-risk patients of whom 136 (3.5%) ................................................................................
suffered perioperative cardiac death or MI.7–9 A final piece of 18–44 7311 7326 þ2.1
evidence with respect to patient outcome is derived from the 45–64 4111 5210 þ26.7
Perioperative Ischaemic Evaluation (POISE) trial, which was con- 65–74 3069 3036 21.1
ductedthroughout2002–2007,andenrolled8351patientsunder- 75andover 3479 4317 þ24.1
going non-cardiac surgery.10 Perioperative mortality occurred in 18andover 17969 19889 þ10.7
226 patients (2.7%), of whom 133 (1.6%) suffered cardiovascular
death, whereas non-fatal MI was observed in another 367 (4.4%)
subjects. Differences in incidences between the studies are
mainly explained by patient selection and endpoint MI defi-
Purpose
nitions—majornon-cardiacsurgeryisassociatedwithanincidence
of cardiac death of between 0.5 and 1.5%, and of major cardiac CurrentlytherearenoofficialESCguidelinesonpre-operativerisk
complications of between 2.0 and 3.5%. When applied to the assessment and perioperative cardiac management. The objective
population in the European Union member states these figures istoendorseastandardizedandevidence-basedapproachtoperi-
translate into 150 000–250 000 life-threatening cardiac compli- operativecardiacmanagement.Theguidelinesrecommendaprac-
cations dueto non-cardiacsurgical proceduresannually. tical, stepwise evaluation of the patient, which integrates clinical
risk factors and test results with the estimated stress of the
Impact of the ageing population
planned surgical procedure. This results in an individualized
Within the next20 years,the acceleration in ageing of the popu- cardiac risk assessment, with the opportunity to initiate medical
lation will have a major impact on perioperative patient manage- therapy, coronary interventions, and specific surgical and anaes-
ment. It is estimated that elderly people require surgery four thetic techniques in order to optimize the patient’s perioperative
times more often than the rest of the population.11 Although condition.Comparedwiththenon-surgicalsetting,datafromran-
exact data regarding the number of patients undergoing surgery domized clinical trials, which are the ideal evidence base for the
inEuropearelacking,itisestimatedthatthisnumberwillincrease guidelines, are sparse. Therefore, when no trials are available on
by 25% by 2020, and for the same time period the elderly popu- a specific cardiac management regimen in the surgical setting,
lation will increase by .50%. The total number of surgical pro- datafromthenon-surgicalsettingareused,andsimilarrecommen-
cedures will increase even faster because of the rising frequency dations made, but with different levels of evidence. Emphasis is
of interventions with age.12 Results of the US National Hospital placedontherestricteduseofprophylacticcoronaryrevasculari-
DischargeSurveyshowthat,ingeneral,thenumberofsurgicalpro- zation,asthis israrely indicated simply to ensure the patient sur-
cedureswillincreaseinalmostallagegroups,butthatthelargest vives surgery. Pre-operative evaluation requires an integrated
increasewilloccurinthe middle agedandelderly(Table 3). multidisciplinary approach from anaesthesiologists, cardiologists,
Demographics of patients undergoing surgery show a trend internists, pulmonologists, geriatricians, and surgeons. Anaesthe-
towards an increasing number of elderly patients and siologists, who are experts on the specific demands of the pro-
co-morbidities.13 Although mortality from cardiac disease is posedsurgical procedure,usually coordinatethe process.
decreasing in the general population, the prevalence of IHD, Guidelines have the potential to improve post-operative
heart failure, and cardiovascular risk factors, especially diabetes, outcome.However,asshowninanobservationalstudyof711vas-
is increasing. Among the significant co-morbidities in elderly cularsurgerypatientsfromTheNetherlands,adherencetoguide-
patients presenting for general surgery, cardiovascular disease lines is poor.16–18 Although 185 of a total of 711 patients (26%)
(CVD) is the most prevalent. It is estimated from primary care fulfilled the ACC/AHA guideline criteria for pre-operative non-
data that in the 75–84 year age group 19% of men and 12% of invasive cardiac testing, clinicians had performed testing in only
women have some degree of CVD.14 Age per se, however, 38 of those cases (21%).16 The guideline-recommended medical
seems to be responsible for only a small increase in the risk of therapy for the perioperative period, namely the combination of
complications;greaterrisksareassociatedwithurgencyandsignifi- aspirin and statins in all patients and b-blockers in patients with
cantcardiac,pulmonary,andrenaldisease.Thenumberofaffected ischaemic heart disease, was followed in only 41% of cases.18
individuals is likelyto be higher in countries with high CVD mor- Significantly,theuseofevidence-basedmedicationduringtheperi-
tality,particularlyinCentralandEasternEurope.Theseconditions operative period was associated with a reduction in 3-year mor-
should, therefore, have a greater impact on the evaluation of tality after adjustment for clinical characteristics [hazard ratio
patientrisk than agealone. (HR), 0.65; 95% confidence interval (CI), 0.45–0.94]. These data
2774 ESCGuidelines
highlight the existence of a clear opportunity for improving the Although patient-specific factors are more important than
qualityofcareinthis high-riskgroupofpatients. surgery-specific factors in predicting the cardiac risk for non-
In addition to promoting an improvement in immediate perio- cardiac surgical procedures, the type of surgery cannot be
perative care, guidelines should provide long-term advice, as ignored when evaluating a particular patient undergoing an inter-
patients should live long enough to enjoy the benefits of surgery. vention.6,20 With regard to cardiacrisk, surgical interventions can
Following the development and introduction of perioperative be divided into low-risk, intermediate-risk, and high-risk groups
cardiac guidelines, their effect on outcome should be monitored. with estimated 30-day cardiac event rates (cardiac death and MI)
Theobjectiveevaluationofchangesinoutcomewillbeanessential of ,1, 1–5, and .5%, respectively (Table 4). Although only a
part offuture perioperativeguidelinedevelopments. roughestimation,thisriskstratificationprovidesagoodindication
oftheneedforcardiacevaluation,drugtreatment,andassessment
ofrisk forcardiac events.
Pre-operative evaluation
The high-risk groupconsistsof major vascular interventions. In
theintermediate-riskcategorytheriskalsodependsonthemagni-
Surgical risk for cardiac events
tude, duration, location, blood loss, and fluid shifts related to the
Cardiac complications after non-cardiac surgery depend not only specificprocedure.Inthelow-riskcategorythecardiacriskisneg-
onspecificriskfactorsbutalsoonthetypeofsurgeryandthecir- ligible unlessstrong patient-specificrisk factors are present.
cumstancesunderwhichittakesplace.19Surgicalfactorsthatinflu- Theneedfor,andvalueof,pre-operativecardiacevaluationwill
encecardiacriskarerelatedtotheurgency,magnitude,type,and also depend on the urgencyof surgery. In the case of emergency
duration of the procedure, as well as the change in body core surgical procedures, such as those for ruptured abdominal aortic
temperature,blood loss, andfluid shifts.12 aneurysm (AAA), major trauma, or for perforated viscus, cardiac
Every operation elicits a stress response. This response is evaluationwillnotchangethecourseandresultoftheintervention
initiated by tissue injury and mediated by neuroendocrine but may influence the management in the immediate post-
factors, and may induce tachycardia and hypertension. Fluid shifts operative period. In non-emergent but urgent untreated surgical
in the perioperative period add to the surgical stress. This stress conditions such as bypass for acute limb ischaemia or treatment
increases myocardial oxygen demand. Surgery also causes altera- ofbowelobstruction,themorbidityandmortalityoftheuntreated
tions in the balance between prothrombotic and fibrinolytic underlying condition will outweigh the potential cardiac risk
factors, resulting in hypercoagulability and possible coronary relatedtotheintervention.Inthesecases,cardiologicalevaluation
thrombosis (elevation of fibrinogen and other coagulation may influence the perioperative measures taken to reduce the
factors, increased platelet activation and aggregation, and cardiac risk, but will not influence the decision to perform the
reducedfibrinolysis).Theextentofsuchchangesisproportionate intervention. In some cases, the cardiac risk can also influence
to the extent and duration of the intervention. All these factors the type of operation and guide the choice to less invasive inter-
may cause myocardial ischaemia and heart failure. Certainly in ventions, such as peripheral arterial angioplasty instead of infra-
patients at elevated risk, attention to these factors should be inguinal bypass, or extra-anatomic reconstruction instead of
givenandlead, ifindicated, toadaptations inthesurgical plan. aortic procedure, even when these may yield less favourable
Table4 Surgicalriskaestimate(modifiedfromBoersmaetal.6)
aRiskofMIandcardiacdeathwithin30daysaftersurgery.
ESCGuidelines 2775
Table5 LeeindexandErasmusmodel:clinicalriskfactorsusedforpre-operativecardiacriskstratification5,6
Clinicalcharacteristics Leeindex Erasmusmodel
...............................................................................................................................................................................
IHD(anginapectorisand/orMI) x x
Surgicalrisk High-risksurgery High,intermediate-high,intermediate-low,lowrisk
Heartfailure x x
Stroke/transientischaemicattack x x
Diabetesmellitusrequiringinsulintherapy x x
Renaldysfunction/haemodialysis x x
Age x
IHD¼ischaemicheartdisease;MI¼myocardialinfarction.
results in the long term. Lastly, in some situations, the cardiac laparoscopy compared with open surgery, and both should be
evaluation,in asfarasitcanreliablypredict perioperativecardiac evaluatedinthesameway.Thisisespeciallytrueinpatientsunder-
complicationsandestimatelatesurvival,shouldbetakenintocon- going interventions for morbidobesity.24,25
siderationevenwhendecidingwhethertoperformanintervention
ornot.Thisisthecaseincertainprophylacticinterventionssuchas Recommendation/statementonsurgicalriskestimate
the treatment of small AAAs or asymptomatic carotid stenosis
wherethelifeexpectancyofthepatientandtheriskoftheoper- Recommendation/statement Classa Levelb
................................................................................
ation are important factors in evaluating the potential benefit of
Laparoscopicproceduresdemonstrateacardiac I A
thesurgical intervention.
stresssimilartoopenproceduresanditis
Vascularinterventionsareofspecificinterest,notonlybecause
recommendedthatpatientsbescreenedprior
they carry the highest risk of cardiac complications, explained by tointerventionaccordingly
the high probability that the atherosclerotic process also affects
the coronary arteries, but also because of the many studies that aClassofrecommendation.
haveshownthatthisriskcanbeinfluencedbyadequateperiopera- bLevelofevidence.
tivemeasuresinthesepatients.Openaorticandinfra-inguinalpro-
cedures have both to be considered as high-risk procedures.6
Functional capacity
Althoughalessextensiveintervention,infra-inguinalrevasculariza-
tionentailsacardiacrisksimilartoorevenhigherthanaorticpro- Determinationoffunctionalcapacityisconsideredtobeapivotal
cedures. This can be explained by the higher incidence of stepinpre-operativecardiacriskassessment.Functionalcapacityis
diabetes, renal dysfunction, IHD, and advanced age in this patient measured in metabolic equivalents (METs). One MET equals the
group.Thisalsoexplainswhytheriskrelatedtoperipheralartery basalmetabolicrate.Exercisetestingprovidesanobjectiveassess-
angioplasties,whichareminimallyinvasiveprocedures,isnotnegli- ment of functional capacity. Without testing, functional capacity
gible.Severalrandomizedtrials,aswellascommunity-basedstudies, can be estimated by the ability to perform the activities of daily
haveshownthatthecardiacriskissubstantiallylowerafterendovas- living. Given that 1 MET represents metabolic demand at rest,
cularaorticaneurysmrepaircomparedwithopenrepair.21Thiscan climbing two flights of stairs demands 4 METs, and strenuous
berelatedtothelessertissuedamageandtheavoidanceofaortic sportssuch asswimming .10 METS(Figure 1).
cross-clampingandpost-operativeileus.However,long-termsurvi- Theinabilitytoclimbtwoflightsofstairsorrunashortdistance
valdoesnotseemtobeinfluencedbythesurgicaltechniquethatis (,4 METs) indicates poor functional capacity and is associated
used,butisdeterminedbytheunderlyingcardiacdisease.22Carotid with an increased incidence of post-operative cardiac events.
endarterectomyisconsideredtobeanintermediate-riskprocedure. Afterthoracicsurgery,apoorfunctionalcapacityhasbeenassoci-
Nevertheless,elevatedcardiacriskandlatesurvivalshouldbetaken ated with an increased mortality (relative risk 18.7, 95% CI 5.9–
intoaccountinthedecision-makingprocessandcaninfluencethe 59). However, in comparison with thoracic surgery, a poor func-
choicebetweenendarterectomyorstenting. tional status was not associated with an increased mortality after
Laparoscopic procedures have the advantage of causing less other non-cardiac surgery (relative risk 0.47, 95% CI 0.09–2.5).28
tissue trauma and intestinal paralysis compared with open pro- This may reflect the importance of pulmonary function, strongly
cedures, resulting in less incisional pain and diminished post- related to functional capacity, as a major predictor of survival
operative fluid shifts related to bowel paralysis.23 On the other after thoracic surgery. These findings were confirmed in a study
hand, the pneumoperitoneum used in these procedures results of 5939 patients scheduled for non-cardiac surgery in which the
in elevated intra-abdominal pressure and a reduction in venous prognostic importance of pre-operative functional capacity was
return.Itwillresultinadecreaseincardiacoutputandanincrease measured in METs.29 Using receiver operating characteristic
in systemic vascular resistance. Therefore, cardiac risk in patients (ROC) curve analysis, the association of functional capacity with
with heart failure is not diminished in patients undergoing post-operative cardiac events or death showed an area under
2776 ESCGuidelines
Figure 1 Estimated energy requirements for various activities. km per h¼kilometres per hour; MET¼metabolic equivalent. Based on
Hlatkyetal.26andFletcheretal.27
the ROC curve of just 0.664, compared with 0.814 for age. the evaluation must necessarily be limited. However, most clinical
Considering the relatively weak association between functional circumstancesallowtheapplicationofamoreextensive,systematic
capacity and post-operative cardiac outcome, what importance approach,withcardiacriskevaluationthatisinitiallybasedonclinical
should we attach to functional capacity assessment in the pre- characteristics and type of surgery, and then extended—if indi-
operative evaluation of the risk of non-cardiac surgery? When cated—to resting electrocardiography (ECG),laboratory measure-
functional capacity is high, the prognosis is excellent, even in the ments,andnon-invasive(stress)testing.
presenceofstableIHDorriskfactors.30Inthiscase,perioperative Duringthelast30years,severalriskindiceshavebeendeveloped,
management will rarely be changed as a result of further cardiac based on multivariable analyses of observational data, which rep-
testing and the planned surgical procedure can proceed. Using resent the relationship between clinical characteristics and perio-
functional capacity evaluation prior to surgery, the ability to perative cardiac mortality and morbidity. The indices that were
climb two flights of stairs or run for a short distance indicated a developed by Goldman (1977), Detsky (1986), and Lee (1999)
good functional capacity. On the other hand, when functional becamewellknown.5,31,32TheLeeindex,whichisinfactamodifi-
capacity is poor or unknown, the presence and number of risk cation of the original Goldman index, is considered by many clini-
factors in relation to the risk of surgery will determine pre- cians and researchers to be the best currently available cardiac
operativeriskstratificationandperioperativemanagement. risk prediction index in non-cardiac surgery. It was developed
using prospectively collected data on 2893 unselected patients
Risk indices
(and validated in another 1422 patients) who underwent a wide
Effective strategies aimed at reducing the risk of perioperative spectrumofprocedures.Theywerefollowedsystematicallythrough-
cardiac complications should involve cardiac evaluation using outthepost-operativephaseforarangeofclinicallyrelevantcardiac
medical history prior to the surgical procedure, for two main outcomes.TheLeeindexcontainsfiveindependentclinicaldetermi-
reasons. First, patients with an anticipated low cardiac risk—after nants of major perioperative cardiac events: a history of IHD, a
thorough evaluation—can be operated on safely without further history of cerebrovascular disease, heart failure, insulin-dependent
delay.Itisunlikelythatriskreductionstrategiescanreducetheperi- diabetes mellitus, and impaired renal function. High-risk type of
operative risk further. Secondly, risk reduction by pharmacological surgery is the sixth factor that is included in the index. All factors
treatment is most cost-effective in patients with a suspected contribute equally to the index (with 1 point each), and the inci-
increasedcardiacrisk.Additionalnon-invasivecardiacimagingtech- dence of major cardiac complications is estimated at 0.4, 0.9, 7,
niquesaretoolstoidentifypatientsathigherrisk.However,imaging and11%inpatientswithanindexof0,1,2,and(cid:2)3points,respect-
techniques should be reserved for those patients in whom test ively.TheareaundertheROCcurveinthevalidationdatasetwas
results would influence and change management. Obviously, the 0.81,indicatingthattheindexhasahighcapabilityfordiscriminating
intensity of the pre-operative cardiac evaluation must be tailored betweenpatientswithandwithoutamajorcardiacevent.
to the patient’s clinical condition and the urgency of the circum- However,thepatientsstudiedbyLeeetal.cannotbeconsidered
stances requiring surgery. When emergency surgery is needed, to beanaverage,unselectednon-cardiacsurgical cohort. Patients
ESCGuidelines 2777
undergoingthoracic(12%),vascular(21%),andorthopaedicsurgery high-sensitivity troponins, will further enhance the assessment of
(35%)wereover-represented.Furthermore,despiteitsrespectable myocardial damage. It should be noted that troponin elevation
size,thestudywastoounderpoweredtorevealabroadrangeof may be observed in many other conditions. The diagnosis of
cardiac outcome determinants, as only 56 cardiac events were non-ST-segment elevation myocardial infarction (NSTEMI)
observed in the derivation cohort. Several external validation should neverbe made solelyon thebasis ofbiomarkers.
studies have suggested that the Lee index is probably suboptimal Inflammatory markers might identify pre-operatively those
for identifying patients with multiple risk factors.6 In fact, the patients with an increased risk of unstable coronary plaque. C-
typeofsurgerywasonlyclassifiedastwosubtypes:first,high-risk, reactive protein (CRP) is an acute-phase reactant produced in the
including intraperitoneal, intrathoracic, and suprainguinal vascular liver.CRPisalsoexpressedinsmoothmusclecellswithindiseased
procedures; and, secondly, all remaining non-laparoscopic pro- atheroscleroticarteriesandhasbeenimplicatedinmanyaspectsof
cedures,mainlyincludingorthopaedic,abdominal,andothervascu- atherogenesis and plaque vulnerability, including expression of
larprocedures.Evidenceexiststhatamoresubtleclassification,such adhesion molecules, induction of nitric oxide, altered complement
astheErasmusmodel,resultsinbetterriskdiscrimination.6Inthis function, and inhibition of intrinsic fibrinolysis.38 However, in the
model, an extensive description of the type of surgery and age surgical setting, no data are currently available using CRP as a
increased the prognostic value of the model for perioperative markerfortheinitiationofriskreductionstrategies.
cardiacevents(areaundertheROCcurveforthepredictionofcar- Brain natriuretic peptide (BNP) and N-terminal pro-BNP
diovascularmortalityincreasedfrom0.63to0.85). (NT-proBNP) are produced in cardiac myocytes in response to
increases in myocardial wall stress. This may occur at any stage
Recommendations/statementsoncardiacrisk ofheartfailure,independentlyofthepresenceorabsenceofmyo-
stratification cardial ischaemia. Plasma BNP and NT-proBNP have emerged as
important prognostic indicators in patients with heart failure,
Recommendations/statements Classa Levelb ACS, and stable IHD in non-surgical settings.39–41 Pre-operative
................................................................................
BNP and NT-proBNP levels have additional prognostic value for
Itisrecommendedclinicalriskindicesbeusedfor I B
long-termmortalityandforcardiaceventsaftermajornon-cardiac
post-operativeriskstratification
vascularsurgery.42–46
ItisrecommendedthattheLeeindexmodel I A
Data on pre-operative biomarker use from prospective con-
applyingsixdifferentvariablesforperioperative
cardiacriskbeused trolledtrialsaresparse.Basedonthepresentdata,routineassess-
ment of serum biomarkers for patients undergoing non-cardiac
aClassofrecommendation. surgery cannot be proposed for routine use as an index of cell
bLevelofevidence. damage.
Recommendations/statementsonbiomarkers
Biomarkers
A biological marker—biomarker—is a characteristic that can be Recommendations/statements Classa Levelb
................................................................................
objectively measured and evaluated and which is an indicator of
NT-proBNPandBNPmeasurementsshouldbe IIa B
abnormal biological and pathogenic processes or responses to
consideredforobtainingindependent
therapeuticinterventions.Intheperioperativesetting,biomarkers
prognosticinformationforperioperativeand
canbedividedintomarkersfocusingonmyocardialischaemiaand latecardiaceventsinhigh-riskpatients.
damage,inflammation, andLV function. Routinebiomarkersamplingtopreventcardiac III C
Cardiac troponins T and I (cTnT and cTnI) are the preferred eventsisnotrecommended
markers for the diagnosis of MI because they demonstrate sensi-
tivity and tissue specificity superior to other available bio- aClassofrecommendation.
markers.33,34 The prognostic information is independent of, and bLevelofevidence.
BNP¼brainnatriureticpeptide;NT-proBNP¼N-terminalpro-brainnatriuretic
complementary to, other important cardiac indicators of risk
peptide.
such as ST deviation and LV function. The prognostic significance
of even small elevations in troponins has been independently
Non-invasive testing
confirmed in community-based studies and in clinical trials
(TACTICS-TIMI 18, FRISC II, OPUS-TIMI),35,36 not only in high- Pre-operativenon-invasivetestingaimsatprovidinginformationon
risk, but also in intermediate-risk groups. cTnI and CTnT seem three cardiac risk markers: LV dysfunction, myocardial ischaemia,
to be of similar value for risk assessment in ACS in the presence and heart valve abnormalities, all major determinants of adverse
and absence of renal failure.33 The prognosis for all-cause death post-operative outcome. LV function is assessed at rest, and
in patients with end-stage renal disease and with even minor various imaging modalities are available. For myocardial ischaemia
elevations in cTnT is 2–5 times worse than for those with detection, exercise ECG and non-invasive imaging techniques may
undetectable values. Existing evidence suggests that even small be used. The overall theme is that the diagnostic algorithm for
increases in cTnT in the perioperative period reflect clinically risk stratification of myocardial ischaemia and LV function should
relevant myocardial injury with worsened cardiac prognosis be similar tothat proposed for patientsinthe non-surgical setting
and outcome.37 The development of new biomarkers, including with known or suspected IHD.47 Non-invasive testing should not
2778 ESCGuidelines
only be considered for coronary artery revascularization but also MIorcardiacdeath.51 Thelimited predictivevalueofLV function
for patient counselling, change of perioperative management in assessment for perioperative outcome may be related to the
relation to type of surgery, anaesthetic technique, and long-term failure to detect severe underlying IHD. Recommendations for
prognosis. Echocardiography is preferred for evaluation of valve the pre-operative evaluation of (asymptomatic) patients with
disease (see sectiononspecificdiseases, subheading valvularheart cardiacmurmurs are discussedinthe section onVHD.
disease).
Recommendationsonrestingechocardiography
Non-invasive testing of cardiac disease
Recommendations Classa Levelb
Electrocardiography ................................................................................
The12-leadECGiscommonlyperformedaspartofpre-operative
RestechocardiographyforLVassessmentshould IIa C
cardiovascular risk assessment in patients undergoing non-cardiac beconsideredinpatientsundergoinghigh-risk
surgery.InIHDpatients,thepre-operativeelectrocardiogramcon- surgery
tains important prognostic information and is predictive of long- RestechocardiographyforLVassessmentin III B
term outcome independent of clinical findings and perioperative asymptomaticpatientsisnotrecommended
ischaemia.48 However, the electrocardiogram may be normal or
non-specific in a patient with either ischaemia or infarction. The aClassofrecommendation.
bLevelofevidence.
routine use of ECG prior to all types of surgery is a subject of LV¼leftventricular.
increasing debate. A retrospective study investigated 23 036
patients scheduled for 28 457 surgical procedures; patients with
abnormal ECG findings had a greater incidence of cardiovascular Non-invasive testing of ischaemic heart
death than those with normal ECG results (1.8% vs. 0.3%). In disease
patients who underwent low-risk or low- to intermediate-risk
Physiologicalexerciseusingatreadmillorbicycleergometeristhe
surgery,theabsolutedifferenceintheincidenceofcardiovascular
preferred method for detection of ischaemia. Physiological exer-
death between those with and without ECG abnormalities was
cise provides an estimate of functional capacity, provides blood
only 0.5%.49
pressure and heart rate response, and detects myocardial ischae-
mia through ST-segment changes. The accuracy of exercise ECG
RecommendationsonECG
varies significantly among studies. Meta-analysis of the reported
studies using treadmill testing in vascular surgery patients
Recommendations Classa Levelb
................................................................................ showedaratherlowsensitivity(74%,95%CI60–88%)andspeci-
Pre-operativeECGisrecommendedforpatients I B ficity (69%, 95% CI 60–78%), comparablewith daily clinical prac-
whohaveriskfactor(s)andarescheduledfor tice.51 The positive predictive value was as low as 10%, but the
intermediate-orhigh-risksurgery negativepredictivevaluewasveryhigh(98%).However,riskstra-
Pre-operativeECGshouldbeconsideredfor IIa B tification with exercise is not suitable for patients with limited
patientswhohaveriskfactor(s)andare
exercise capacity due to their inability to reach an ischaemic
scheduledforlow-risksurgery
threshold. Furthermore, pre-existing ST-segment abnormalities,
Pre-operativeECGmaybeconsideredfor IIb B
especiallyinthepre-cordialleadsV andV atrest,hamperreliable
patientswhohavenoriskfactorandare 5 6
scheduledforintermediate-risksurgery ST-segmentanalysis.Agradientofseverityinthetestresultrelates
Pre-operativeECGisnotrecommendedfor III B totheperioperativeoutcome:theonsetofamyocardialischaemic
patientswhohavenoriskfactorandare response at low exercise workloads is associated with a signifi-
scheduledforlow-risksurgery cantly increased risk of perioperative and long-term cardiac
events.Incontrast,theonsetofmyocardialischaemiaathighwork-
aClassofrecommendation. loads is associated with significantly less risk.30 Pharmacological
bLevelofevidence.
ECG¼electrocardiography. stresstestingwitheithernuclearperfusionimagingorechocardio-
graphyismoresuitableinpatientswithlimitedphysicalcapabilities.
Theroleofmyocardialperfusionimagingforpre-operativerisk
Assessment of left ventricular function
stratification is well established. In patients with limited exercise
Resting LV function can be evaluated before non-cardiac surgery capacity, pharmacological stress (dipyridamole, adenosine, or
by radionuclide ventriculography, gated single photon emission dobutamine) is an alternative stressor. Images reflect myocardial
computed tomography (SPECT) imaging, echocardiography, mag- blood distribution at the time of injection. Studies are performed
netic resonance imaging (MRI), or multislice computed tomogra- bothduringstressandatresttodeterminethepresenceofrevers-
phy (CT), with similar accuracy.50 Routine echocardiography is ibledefects,reflectingjeopardizedischaemicmyocardium,orfixed
notrecommendedforthepre-operativeevaluationofLVfunction, defects, reflecting scarornon-viabletissue.
butmaybeperformedinasymptomaticpatientsundergoinghigh- The prognostic value of the extent of ischaemic myocardium,
risk surgery. A meta-analysis of the available data demonstrated using semi-quantitative dipyridamole myocardial perfusion
that an LV ejection fraction of ,35% had a sensitivity of 50% imaging,has beeninvestigated ina meta-analysisof studies in vas-
and a specificity of 91% for prediction of perioperative non-fatal cular surgery patients.52 Study endpoints were perioperative