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Highlights on the 2014 ESC/ESA Guidelines on non-cardiac surgery: cardiovascular assessment and management

Presentation by Per Anton Sirnes, FESC, previous chair of the ESC Council for Cardiology Practice (2010-2012) and member of the ESC Committee for Practice Guidelines’ task force for the writing of the 2014 ESC/ESA guidelines on non-cardiac surgery.

Preoperative initiation of beta-adrenergic blocker
The 2009 GL recommended the use of β-blockers with Ia recommendation for patients scheduled for high risk surgery and IIa for intermediate risk surgery and IIb for low-risk surgery. These recommendations were in part based on the DECREASE family of studies, led by the Dutch investigator (and chair of previous non-surgical GL task force) Dr Poldermans, whose scientific conduct regarding these studies was later heavily questioned (2). The GL task force was therefore instructed to review the use of β-blockers without taking into considerations any of the DECREASE publications. All references to Dr Poldermans work was to be omitted.  Although a meta-analysis which excluded the Poldermans publications still found an increased mortality of preoperative β-blockade (3), this was very heavily influenced by the POISE study ( 4), which used high dosed metoprolol without titration and was judged as less clinically relevant.  After considering all available evidence, the recommendations for β-blockers were downgraded, but not omitted. The new GL concluded that peri-operative initiation of β-blockers may be considered (Grade IIb) in patients scheduled for high-risk surgery who have two clinical risk factors or ASA status ≥3 (see below). Likewise clinically indicated β-blockade should be continued pre and perioperative and β-blockade may further be initiated in due time before surgery when there is a clinical indication such as ischemic heart disease, heart failure or arrhythmia.

The 2009 GL recommended statins to be started in all patients undergoing high risk surgery  (I, LOE B), whereas the 2014 GL modifies this to a IIa (LOE B) recommendation to considered to start stain in patients undergoing vascular surgery, ideally at least 2 weeks before surgery.

α2- receptor agonists
The use of α2-receptor agonists like clonidine received a IIb recommendation to reduce complications in vascular surgery patients in the 2009 GL. However, a recent randomized study (5) showed that pre-operative initiation of such drugs did not decrease mortality, but increased the frequency of hypotension and cardiac arrest. Thus, preoperative initiation of α2-receptor agonists is now contraindicated.

Anti-platelet therapy and anticoagulation
Regarding aspirin use, the 2009 GL stated that “continuation of aspirin in patients previously treated with aspirin should be considered in the perioperative period” (IIa), and discussed the possible benefits of aspirin regarding cardiovascular protection.  The POISE-2 study (6), which randomized 10000 patients to aspirin or placebo before non-cardiac surgery, did not show any reduction of death or myocardial infarction, but significantly more bleeding.  The 2014 GL has thus a less positive attitude regarding aspirin and states that “continuation of aspirin, in patients previously thus treated, may be considered in the perioperative period, and should be based on an individual decision that depends on the perioperative bleeding risk, weighed against the risk of thrombotic complications (IIb -B). Discontinuation of aspirin should be considered for those in whom haemostasis is anticipated to be difficult to control during surgery. The new guidelines are updated regarding double platelet inhibition after PCI and recommends that aspirin be continued for 4 weeks after BMS implantation and for 3–12 months after DES implantation, unless the risk of life-threatening surgical bleeding on aspirin is unacceptably high.  New oral anticoagulants have emerged in general use since the last GL and the new overall recommendation is to stop NOACs for 2–3 times their respective biological half-lives prior to surgery in surgical interventions with ‘normal’ bleeding risk, and 4–5 times the biological half-lives before surgery in surgical interventions with high bleeding risk.

Revascularization and preoperative angiography and exercise testing
The “risk free” period in whom asymptomatic high-risk patients with prior CABG could go straight to surgery without angiographic evaluation has been increased from 5 to 6 years.   For patients with recent BMS, consideration should be given to performing non-urgent, non-cardiac after a minimum of 4 weeks  (this was 6 weeks in the previous GL), and ideally 3 months following the intervention. Whereas the 2009 GL recommended at least 12 months delay for non-cardiac surgery after DES implantation, the 2014 GL opens to reduce this delay to 6 months for the newest generation DES. Regarding revascularization, both the new and old GL refer to the ESC guidelines for chronic stable coronary artery disease for decision-making. The 2009 GL states (IIb-B) that “prophylactic myocardial revascularization prior to high-risk surgery may be considered in patients with proven IHD”, the 2014 GL adds that this may be considered (IIb), depending on the extent of a stress-induced perfusion defect.

Heart failure
Heart failure is one of the most important risk factors for operative death and re-admission. The Section on heart failure has been updated and re-written and there is a recommendation table, which was lacking in the 2009 GL. It is recommended that patients with established or suspected heart failure, and who are scheduled for non-cardiac intermediate or high-risk surgery, should undergo evaluation of LV function with transthoracic echocardiography and/or assessment of natriuretic peptides, unless they have recently been assessed for this. Heart failure treatment should be optimized according to the ESC HF GL. In patients with newly diagnosed heart failure, it is recommended that intermediate- or high-risk surgery be deferred, preferably for at least 3 months after initiation of heart failure therapy, to allow time for therapy up-titration and possible improvement of LV function.

Valvular Heart Disease
The impact of valvular heart disease is discussed in detail. The most important VHD is aortic stenosis. The crucial factor is whether the patient is asymptomatic or not. If possible, the absence of symptoms should be confirmed by exercise testing. Even in patients with severe aortic stenosis, low and intermediate risk surgery may be performed safely if the patient is asymptomatic. In symptomatic patients with severe AS, aortic valve replacement should be considered before elective surgery. TAVI is emerging as a choice in patients at high risk or with contra-indicated for operative aortic valve replacement.

Biomarkers as natriuretic peptides and high sensitive troponins are increasingly used to assess cardiac patients and this is also reflected in the new guideline. The 2009 GL recommended measurements of natriuretic peptides to be considered in high-risk patients. The 2014 GL states that assessment of natriuretic peptides should form part of a routine pre-operative evaluation when cardiac dysfunction is known or suspected and that assessment of cardiac troponins in high-risk patients, both before and 48–72 hours after major surgery, may be considered.

Preoperative ECG
Whether all patients scheduled for non-cardiac surgery should have an ECG is often debated in many hospitals. The main conclusion is not very different between the two GL. Pre-operative ECG is recommended (I-B) for patients with risk factors who are scheduled for intermediate – or high risk surgery. For patients with risk factors scheduled for low-risk surgery, the ECG recommendation has been downgraded from IIa to IIb (may be considered). For patients without risk factors who are going to intermediate-risk surgery, age above 65 has come in as an extra criterion for ECG (IIb). Routine ECG is not recommended for for patients who have no risk factors and are scheduled for low-risk surgery.

For patients with significant valvular disease or established or suspected heart failure, and who are scheduled for non-cardiac intermediate or high-risk surgery, evaluation of LV function and valves with transthoracic echocardiography is recommended with IA. For other patients the routine use of echo has been somewhat downgraded: the  2009 GL stated that rest echocardiography for LV assessment should be considered in patients undergoing high-risk surgery (IIa–C), whereas the 2014 GL states that an echo may be considered (IIb–C).

Risk indices
Whereas the Lee index was the proposed index in the 2009 GL, the new GL also recommends the NSQIP index, which is also available on line: ( This model incorporates five main predictors:

  • Age
  • Type of surgery
  • Functional status
  • Elevated creatinine
  • American Society of Anaesthesiologist (ASA) class
    • I:   completely healthy
    • II:  mild systemic disease
    • III: severe non-incapacitating systemic disease
    • IV: incapacitating disease that is not a constant threat to life
    • V: moribund patient, not expected to live > 24 hrs
The table of the cardiac risk associated with different procedures has also been expanded and modified (Fig 2).

Multidisciplinary team and a stepwise approach
The role of a multi-disciplinary team is emphasized and a schedule for a stepwise approach for assessing the risk in non-cardiac surgery is presented (Fig 3).

Fig1. 2014 Recommendation on peri-operative β-blocker use

Fig2. Table of the risk associated with different procedures

Fig3. Summary of pre-operative cardiac risk evaluation and perioperative management.

The 2014 ESC/ESA Guidelines on non-cardiac surgery: cardiovascular assessment and management is a very useful document for the clinical cardiologist assessing patients scheduled for non-cardiac surgery. The full document is very readable and should be downloaded by all who perform such assessments. In addition there is a handy pocket-size GL summery with all main recommendation tables.

Authors: Per Anton Sirnes, FESC, Chair of the ESC Council for Cardiology Practice (2010-2012) and member of the ESC Committee for Practice Guidelines’ task force for the writing of the 2014 ESC/ESA guidelines on non-cardiac surgery.


  1. 2014 ESC/ESA Guidelines on non-cardiac surgery: cardiovascular assessment and management Eur Heart J  2014;35:2383-2431


  3. Bouri S, Shun-Shin MJ, Cole GD, Mayet J, Francis DP. Meta-analysis of secure randomised controlled trials of beta-blockade to prevent peri-operative death in noncardiac surgery. Heart 2014;100:456–464.

  4. Devereaux PJ, YangH, Yusuf S, Guyatt G, Leslie K, Villar JC et al. Effects of extendedrelease metoprolol succinate in patients undergoing non-cardiac surgery (POISE trial): a randomised controlled trial. Lancet 2008;371 :1839–1847

  5. Devereaux PJ, Sessler DI, Leslie K, Kurz A, Mrkobrada M, Alonso-Coello P et al. Clonidine in patients undergoing noncardiac surgery. N Engl J Med 2014;370: 1504–1513.

  6. Devereaux PJ, Mrkobrada M, Sessler DI, Leslie K, Alonso-Coello P, Kurz A et al. Aspirin in patients undergoing noncardiac surgery. N Engl J Med 2014;370:1494–1503

All figures come from the 2014 ESC/ESA Guidelines on non-cardiac surgery: cardiovascular assessment and management.