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Raffaele De Caterina
G. d’Annunzio University
Chieti, Italy
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Such risk depends on the condition of the patient prior to surgery, the prevalence of co-morbidities, and the magnitude and duration of the surgical procedure.
Cardiac complications are more likely to occur in patients with documented or asymptomatic ischaemic heart disease, left ventricular dysfunction, and valvular heart disease undergoing surgical procedures associated with prolonged haemodynamic and cardiac stress.
After major surgery the incidence of cardiac death varies between 0.5% and 1.5%, and of nonfatal cardiac complications between 2.0% and 3.5%. When applied to the population in EU member states these figures translate into 150,000 to 250,000 life-threatening cardiac complications from non-cardiac surgical procedures each year, underlying the magnitude and importance of this topic. Cardiologists are confronted each day with a need to decrease such a risk without unnecessarily delaying surgery.
An appropriate streamlined decision algorithm appears essential to ensure the patient’s safety, but also to allocate economic resources optimally. The inappropriate referral to cardiological tests and examinations that remain without practical consequence to the patient’s treatment or result, in the worst cases, in iatrogenic damage seems a common problem. The first ESC Guidelines on this topic convey the best scientific evidence in this complicated area.
The
Guidelines for Preoperative Cardiac Risk Assessment and Perioperative Cardiac Management in Noncardiac Surgery first review the scientific evidence on the problem, describing the use of drugs and treatments in general and in special circumstances.
However, they also recommend a practical, stepwise evaluation of the patient,
integrating cardiac risk factors and test results with the estimated stress of the planned surgical procedure. For each step the class of the recommendation and the strength of evidence is presented. This results in an individualised cardiac risk assessment with the opportunity to initiate medical therapy, coronary interventions and specific surgical and anaesthetic techniques according to the patient’s best needs. Emphasis is put on a restricted use of prophylactic coronary revascularisation, as this is rarely indicated just to get the patient through surgery.
The guidelines consist of 11 Tables and four Figures, and a series of recommendations, each with their appropriate level of evidence. Particularly valuable are recent discussions on the use of perioperative beta-blockers, and on the practical management of patients treated with coronary bypass surgery or PCI with different types of stents.
Emphasis is put on the bridging protocols for antiplatelet and anticoagulant treatment to ensure the best compromise between optimal haemostasis at surgery and protection from thrombosis, and on the various alternatives available.
European cardiologists will find the full text of these guidelines the most up-to-date and comprehensive reference source on this hot topic; in addition, the accompanying Pocket Guidelines and PDA format will provide a practical guide for everyday use.
ESC Guidelines for preoperative cardiac risk assessment and perioperative cardiac management in non-cardiac surgery, Monday 31 August 16:30-18:00, Barcelona - Zone 2, FPN 2706-2710