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

Preamble and introduction

• The magnitude of the problem
• Change in demographics
• Purpose and organization

Pre-operative evaluation

• Surgical risk for cardiac events
• Type of surgery
  • Endovascular vs. open vascular procedures
  • Open vs. laparoscopic or thoracoscopic procedures
• Functional capacity
• Risk indices
• Biomarkers
• Non-invasive testing
  • Non-invasive testing of cardiac disease
  • Non-invasive testing of ischaemic heart disease
• Invasive coronary angiography

Risk-reduction strategies

• Pharmacological
  • Beta-blockers
  • Statins 
  • Nitrates
  • angiotensin -converting enzyme inhibitors and angiotensin-receptor blockers 
  • Calcium channel blockers 
  • Alpha2 receptor agonists 
  • Diuretics

• Peri-operative management in patients on anti-platelet agents
  • Aspirin
  • Dual anti-platelet therapy 
  • Reversal of anti-platelet therapy

• Peri-operative management in patients on anticoagulants
  • Vitamin K antagonists
  • Non-vitamin K antagonist oral anticoagulants
  • Reversal of anticoagulant therapy

• Revascularization
  • Prophylactic revascularization in patients with asymptomatic or stable ischaemic heart disease
  • Type of prophylactic revascularization in patients with stable ischaemic heart disease 
  • Revascularization in patients with non-ST-elevation acute coronary syndrome

Specific diseases

• Chronic heart failure
• Arterial hypertension
• Valvular heart disease
  • Patient evaluation 
  • Aortic stenosis 
  • Mitral stenosis
  • Primary aortic regurgitation and mitral regurgitation 
  • Secondary mitral regurgitation 
  • Patients with prosthetic valve(s) 
  • Prophylaxis of infective endocarditis

• Arrhythmias
  • New-onset ventricular arrhythmias in the pre-operative period 
  • Management of supraventricular arrhythmias and atrial fibrillation in the pre-operative period.
  • Peri-operative bradyarrhythmias 
  • Peri-operative management of patients with pacemaker/implantable cardioverter defibrillator 

• Renal disease
• Cerebrovascular disease 
• Peripheral artery disease 
• Pulmonary disease 
• Congenital heart disease

Peri-operative monitoring

• Electrocardiography
• Transoesophageal echocardiography 
• Right heart catheterization
• Disturbed glucose metabolism 
• Anaemia

Anaesthesia

• Intra-operative anaesthetic management
• Neuraxial techniques 
• Peri-operative goal-directed therapy 
• Risk stratification after surgery 
• Early diagnosis of post-operative complications 
• Post-operative pain management

Gaps in evidence
Summary
Appendix
References