Cardiovascular assessment and management of patients undergoing non-cardiac surgery

The occurrence of cardiovascular complications in the peri-operative phase of non-cardiac surgery has impact on prognosis. The new guidelines aim to reduce this risk by giving recommendations in the pre-, peri-, and post-operative field.

The new 2022 guidelines were presented during 2 sessions at the ESC Congress 2022 and published simultaneously online in the European Heart Journal [1–3].

“There is a complex interplay between the intrinsic risk of surgery and the patient risk of peri-operative cardiovascular complications,” said Prof. Sigrun Halvorsen (Oslo University Hospital Ulleval, Norway), Chair of the Guidelines Task Force, in her overview of the new guidelines. To assess the risk, the task force has decided against recommending on a specific score.

Specific surgical interventions are now categorised as low (<1%), intermediate (1–5%), and high (>5%) risk, based on 30-day risk of cardiovascular (CV) death, myocardial infarction (MI), and stroke.

An initial assessment is recommended in all patients scheduled for non-cardiac surgery, which includes accurate history taking and a clinical examination, with special emphasis on CV risk factors, established CVD, and comorbidities. In the new flowchart on recommendations for preoperative assessment before non-cardiac surgery, patients are divided in 3 groups: those <65 years without any CVD/CV risk factors, those ≥65 years or with CV risk factors, and patients with established CVD (see Figure). In the second and third group, assessment of ECG and biomarkers were given a class I recommendation. “This is one of the most important changes in the guidelines, the upgraded biomarker recommendation. Troponin was given a class 1 recommendation because it is useful both for pre-operative risk stratification and for the diagnosis of peri-operative myocardial infarction,” Prof. Halvorsen explained.

Figure: Pre-operative assessment depending on patient characteristics and risk of NCS

There is also a new section for patients with previously unknown murmur, angina, dyspnoea, or peripheral oedema.

Regarding a general risk reduction strategy there are 2 new recommendations:

• Smoking cessation is recommended more than 4 weeks before non-cardiac surgery
• If time allows, guideline-recommended treatment of CVD and CV risk factors before non-cardiac surgery should be optimised

The routine initiation of β-blocker peri-operatively is not recommended.

There are revised recommendations on the peri-operative management of antiplatelets and anticoagulants, and new recommendations on peri-operative thromboprophylaxis. Recommendations are complemented by a couple of new figures, e.g. on P2Y₁₂ inhibitor interruption after percutaneous coronary intervention (PCI) before elective non-cardiac surgery and a flowchart with new recommendations for management of oral anticoagulation therapy. “We are now much more restrictive with respect to bridging compared with before,” Prof. Halvorsen commented. Therefore, bridging of oral anticoagulants therapy is not recommended in patients with low/moderate thrombotic risk undergoing non-cardiac surgery.

New recommendations for management of specific diseases

Prof. Julinda Mehilli (Landshut-Achdorf Hospital, Germany), also Chair of the Guidelines Task Force, presented the second part of the guidelines, namely management of specific diseases, peri-operative monitoring and anaesthesia, and post-operative CV complications.

In coronary artery disease (CAD), stress imaging should be considered before high-risk non-cardiac surgery in asymptomatic patients with poor functional capacity, and prior PCI or coronary artery bypass graft (CABG). Coronary CT angiography should be considered to rule out CAD in patients with suspected chronic coronary syndrome or biomarker-negative non-ST-segment elevation acute coronary syndrome (ACS) in case of low-to-intermediate clinical likelihood of CAD, or in patients not suitable for non-invasive functional testing undergoing non-urgent, intermediate-, and high-risk non-cardiac surgery.

Three new recommendations deal with severe aortic valve stenosis. In a new algorithm, 3 factors determine the management of these patients before non-time sensitive non-cardiac surgery: the symptoms of the patient, the risk of the non-cardiac surgery, and the patient´s risk for valve procedure. “We recommend particularly for symptomatic patients with severe aortic valve stenosis and who have a low risk for valve procedure to undergo valve repair prior to elective intermediate- or high risk non-cardiac surgery,” Prof. Mehilli described the class I recommendation.

There is a new flowchart for the management of severe secondary mitral valve regurgitation in patients scheduled for non-cardiac surgery, where valve intervention (surgical or transcatheter) is recommended depending on patient characteristics and/or risk of non-cardiac surgery.

There are also new recommendations for patients with cardiac implantable electronic devices and arrhythmias. In atrial fibrillation patients with acute or worsening haemodynamic instability undergoing non-cardiac surgery, emergency electrical cardioversion is now recommended (class 1).

“Regarding peripheral artery disease (PAD) and abdominal aortic aneurysm (AAA), only in patients with poor functional capacity or with significant risk factors or symptoms, referral for cardiac work-up and optimisation is recommended prior to elective surgery for PAD but no routine referral,” Prof. Mehilli explained.

In a new class I recommendation, for patients with chronic hypertension undergoing elective non-cardiac surgery, it is recommended to avoid larger peri-operative fluctuations in blood pressure, particularly hypotension, during the peri-operative period.

In the guideline there is a new flowchart on factors associated with peri-operative CV complications divided in patient-related factors, procedure-related factors, and post-operative factors, which play a role. “The most frequent post-operative complication is myocardial injury or infarction in intermediate- or high-risk non-cardiac surgery,” Prof. Mehilli said. There are 2 new recommendations regarding peri-operative CV complications: it is recommended to have high awareness combined with surveillance for peri-operative MI in patients undergoing intermediate- or high-risk non-cardiac surgery. Moreover, systematic peri-operative MI work-up is recommended.

Post-operative atrial fibrillation is seen particularly in patients undergoing intermediate- or high-risk non-cardiac surgery. “Therefore, we propose an algorithm on how to prevent and treat this complication,” Prof. Mehilli said.

1. Presentations in Session: “2022 ESC Guidelines Overview”, ESC Congress 2022, Barcelona, Spain, 26–29 August.
2. Presentations in Session: “2022 ESC-ERS Guidelines on cardiovascular assessment and management of patients undergoing non-cardiac surgery”, ESC Congress 2022, Barcelona, Spain, 26–29 August.
3. Halvorsen S, et al. Eur Heart J. 2022 Aug 26;ehac270. doi: 10.1093/eurheartj/ehac270. Online ahead of print.

 

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Posted on 27 October, 202227 October, 2022