ESC Congress 2022 Barcelona (escardio.org)

2022 ESC Guidelines on cardiovascular assessment and management of patients undergoing non-cardiac surgery – Meet the Guidelines Task Force 
Topic: Noncardiac Surgery / Presurgical Assessment 
Session type: New ESC Guidelines 
Date: 29 August 
Start time: 16:30 
End time: 17:30

The prevalence of comorbidities, the clinical condition of patients before surgery, and the urgency, magnitude, type, and duration of the surgical procedure determine the risk of peri-operative complications. In a recent cohort study of 40 000 patients aged ≥45 years undergoing inpatient NCS, one of seven experienced a major cardiac or cerebrovascular complication at 30 days. Cardiovascular complications can particularly occur in patients with documented or asymptomatic coronary heart disease, left ventricular (LV) dysfunction, valvular heart disease (VHD), and arrhythmias, who undergo surgical procedures that are associated with prolonged haemodynamic and cardiac stress. In the case of peri-operative myocardial ischaemia, three mechanisms are important: (i) oxygen supply–demand mismatch on the background of coronary artery stenosis that may become flow-limiting by peri-operative haemodynamic fluctuations; (ii) acute coronary syndrome (ACS) due to stress-induced erosion or rupture of a vulnerable atherosclerotic plaque in combination with pro-inflammatory and hypercoagulable states induced by surgery, and the haemodynamic distress resulting from fluid shifts and anaesthesia; and (iii) surgery-associated bleeding risk requiring interruption of antiplatelet therapies, which might lead to stent thrombosis among patients undergoing NCS after recent coronary stent placement. Left ventricular dysfunction and arrhythmias may occur for various reasons at all ages. Because the prevalence of CAD, VHD, heart failure, and arrhythmias increases with age, peri-operative CV mortality and morbidity are predominantly an issue in the adult population undergoing major NCS.

In Europe, recent systematic data on the annual number and type of operations, and on patient outcomes are unfortunately lacking. Additionally, data definitions vary, as do data quantity and quality. Based on the estimates outlined above, nearly 6.6 million procedures are performed annually in European patients with CAD, peripheral artery disease (PAD), and cerebrovascular disease who are at high risk of CV complications. In a 7 day cohort study, the European Surgical Outcomes Study (EuSOS) group investigated the outcomes of NCS in 498 hospitals across 27 European nations and the UK; up to 8% of patients undergoing NCS required critical care admission, while in-hospital mortality ranged 1.4–21.5% (mean 4.0%), depending on safety precautions.

Some of the key messages from this guideline include;

The quantification of surgical risk as low, intermediate, and high is helpful in identifying the group of patients who should most benefit from preventive, diagnostic, and therapeutic approaches to concomitant CV conditions.

It is important that patients' values, quality of life, and preferences regarding the benefits and risks of surgery are taken into consideration, and that well-informed patients are involved in the decisions. Risk should be communicated to the patient in absolute terms (e.g. 1 out of 100).

Clinical examination, patient-reported functional capacity, and non-invasive tests represent the cornerstone of pre-operative cardiac assessment.

The peri-operative evaluation of elderly patients who require elective major NCS should include frailty screening, which has proven to be an excellent predictor of unfavourable health outcomes in the older surgical population.

Treatment of pre-existing or newly diagnosed CV conditions (e.g. coronary and peripheral vascular disease, rhythm disorders, and HF) should be individualized according to the pre-operative risk of NCS, and considering the recommendations of speciality guidelines.

A multidisciplinary approach to evaluate whether the treatment of concomitant cardiac conditions before scheduled NCS improves peri-operative safety without unnecessary delay is encouraged.

It is important to clearly and concisely communicate with patients, with simple verbal and written instructions, about changes in medication in the pre- and post-operative phases.

Read more in;

Eur Heart J. 2022 Aug 26;ehac270.  2022 ESC Guidelines on cardiovascular assessment and management of patients undergoing non-cardiac surgery 
2022 ESC Guidelines on cardiovascular assessment and management of patients undergoing non-cardiac surgery | European Heart Journal | Oxford Academic (oup.com)​Sigrun Halvorsen, Julinda Mehilli, Salvatore Cassese, Trygve S Hall, Magdy Abdelhamid, Emanuele Barbato, Stefan De Hert, Ingrid de Laval, Tobias Geisler, Lynne Hinterbuchner, Borja Ibanez, Radosław Lenarczyk, Ulrich R Mansmann, Paul McGreavy, Christian Mueller, Claudio Muneretto, Alexander Niessner, Tatjana S Potpara, Arsen Ristić, L Elif Sade, Henrik Schirmer, Stefanie Schüpke, Henrik Sillesen, Helge Skulstad, Lucia Torracca, Oktay Tutarel, Peter Van Der Meer, Wojtek Wojakowski, Kai Zacharowski, ESC Scientific Document Group; Juhani Knuuti, Steen Dalby Kristensen, Victor Aboyans, Ingo Ahrens, Sotiris Antoniou, Riccardo Asteggiano, Dan Atar, Andreas Baumbach, Helmut Baumgartner, Michael Böhm, Michael A Borger, Hector Bueno, Jelena Čelutkienė, Alaide Chieffo, Maya Cikes, Harald Darius, Victoria Delgado, Philip J Devereaux, David Duncker, Volkmar Falk, Laurent Fauchier, Gilbert Habib, David Hasdai, Kurt Huber, Bernard Iung, Tiny Jaarsma, Aleksandra Konradi, Konstantinos C Koskinas, Dipak Kotecha, Ulf Landmesser, Basil S Lewis, Ales Linhart, Maja Lisa Løchen, Michael Maeng, Stéphane Manzo-Silberman, Richard Mindham, Lis Neubeck, Jens Cosedis Nielsen, Steffen E Petersen, Eva Prescott, Amina Rakisheva, Antti Saraste, Dirk Sibbing, Jolanta Siller-Matula, Marta Sitges, Ivan Stankovic, Rob F Storey, Jurrien Ten Berg, Matthias Thielmann, Rhian M Touyz 
PMID: 36017553 
DOI: 10.1093/eurheartj/ehac270