Today, Professor Sigrun Halvorsen (Oslo University Hospital Ulleval - Oslo, Norway) and Professor Julinda Mehilli (Landshut-Achdorf Hospital - Landshut, Germany), Chairs of the Guidelines Task Force, presented a timely update to ESC Guidelines on CV assessment and management of patients undergoing non-cardiac surgery (NCS).1
The global surgical volume is large and continues to increase. It was estimated that 313 million operations took place in 2012, in 66 countries reporting surgical data, which was a 34% increase over 2004.2 In a US study (2004 to 2013), major CV and cerebrovascular complications occurred in approximately 1 in every 33 hospitalisations for NCS and were a significant source of perioperative morbidity and mortality.3 The prevalence of CV risk factors has increased among patients undergoing major NCS, as has the burden of atherosclerotic CVD.4 Furthermore, the demographics of patients undergoing surgery show trends towards increasing numbers of elderly patients and rising numbers of patients with comorbidities, particularly significant CV, pulmonary and renal disease.1
“We know that the occurrence of CV complications in the peri-operative phase of NCS has a dramatic impact on prognosis,” highlights Prof. Halvorsen.
“A previous edition of guidelines in patients undergoing NCS was published by the ESC and the European Society of Anaesthesiology (ESA) in 2014. Although randomised clinical trials are still relatively scarce compared with non-surgical settings, there is an accumulation of new evidence over the years that necessitates updates to the recommendations,” she says.
Prof. Mehilli explains, “The aim of the new guidelines is to provide a standardised and evidence-based approach. They have the potential to reduce peri- and post-operative complications and highlight a clear opportunity for improving the quality of care.”
The 2022 guidelines highlight that the risk of CV complications in patients undergoing NCS is an interaction between a range of patient-related factors and the type of surgery/procedure plus the circumstances under which the surgery/procedure takes place, for example, the hospital’s experience and whether the procedure is elective or emergency. Specific surgical interventions are now categorised as low (<1%), intermediate (1–5%) and high (>5%) risk, based on 30-day risk of CV death, MI and stroke. It is hoped this will help in the identification of patients who may benefit the most from preventive diagnostic and therapeutic approaches. Risk may be reduced, on an individualised basis, by proper selection of type and timing of the surgical procedure and an adequate pre-operative evaluation of CV risk.
An initial assessment is recommended in all patients scheduled for NCS, which includes accurate history taking and a clinical examination, with special emphasis on CV risk factors, established CVD and comorbidities. Based on this information, recommendations are given regarding additional assessments that should be performed according to age and in patients with established CVD and – new in these guidelines – in those with previously undetected murmurs, angina, dyspnoea or peripheral oedema. Details of when to use pre-operative assessment tools e.g. risk scores, functional capacity quantification, ECG, biomarkers, stress tests and imaging are provided. In addition, the guidelines state that peri-operative evaluation of elderly patients who require elective major NCS should include a frailty screening, which has been shown to be an excellent predictor of unfavourable health outcomes in the older surgical population.
A new section of the 2022 guidelines considers the patient’s perspective. As far as the risks and benefits of NCS are concerned, it is important that patients’ values, quality of life and preferences are addressed, that patients are well informed and that they are involved in decisions. It is recommended that patients are given individualised instructions for pre-operative and post-operative changes in medication, in verbal and written formats with clear and concise directions.
The peri-operative handling of antithrombotic agents is described in detail in an expanded section. Interdisciplinary risk assessment ahead of the intervention is crucial in order to classify patient-related ischaemic and bleeding risks (e.g. by a cardiologist, neurologist, vascular specialist, haematologist etc.) as well as surgical risk (by surgeons and anaesthesiologists). New sections deal with peri-operative thromboprophylaxis and also patient blood management, including intra- and post-operative complications associated with anaemia or blood loss. It is also important to highlight the proposed algorithm for detection and management of peri-operative myocardial injury/infarction and peri-operative atrial fibrillation.
Recommendations for risk assessment and peri-operative management are given for a comprehensive range of specific CVDs and related conditions, including coronary artery disease, known or newly diagnosed arrhythmias, cerebrovascular disease, renal disease, obesity and diabetes, with considerations also provided for patients with cancer or recent COVID-19.
To find out more, read the full 2022 ESC Guidelines on CV assessment and management of patients undergoing NCS – now available in the European Heart Journal.