What are the European Society of Cardiology (ESC) guidelines for cardiac risk assessment and management in patients undergoing non-cardiac surgery?

ESC Guidelines for Non-Cardiac Surgery: Cardiac Risk Assessment and Management

Stepwise Pre-operative Evaluation Algorithm

The 2014 ESC/ESA guidelines recommend a systematic 7-step approach to cardiac risk assessment and perioperative management for patients undergoing non-cardiac surgery. 1

Step 1: Assess Urgency of Surgery

• If urgent/emergency surgery is required, proceed directly to the operating room without delay for cardiac testing or treatment 1
• Provide recommendations on perioperative medical management, surveillance for cardiac events, and continuation of chronic cardiovascular therapy 1
• For non-urgent surgery, proceed to Step 2 1

Step 2: Screen for Active or Unstable Cardiac Conditions

If any active cardiac conditions are present, address these before elective surgery: 1

• Unstable angina or recent myocardial infarction 2, 3
• Decompensated heart failure 2
• Severe valvular disease 2

Management approach: 1

• Discuss treatment options in a multidisciplinary team (anesthesiologist, cardiologist, surgeon) 1
• For unstable angina: Consider coronary intervention with dual antiplatelet therapy if surgery can be delayed, or proceed with optimal medical therapy if delay is impossible 1
• If no active conditions, proceed to Step 3 1

Step 3: Stratify Surgical Risk

Classify surgery into three risk categories based on 30-day risk of cardiovascular death and myocardial infarction: 1

Low-risk surgery (<1% risk): 1

• In patients with clinical risk factors, baseline ECG may be considered for perioperative monitoring 1
• Proceed to surgery 1

Intermediate or high-risk surgery (≥1% risk): 1

• In patients with known ischemic heart disease or myocardial ischemia, initiate titrated low-dose beta-blocker regimen before surgery 1
• In patients with heart failure and systolic dysfunction (LVEF <40%), initiate ACE inhibitors (or ARBs if intolerant) before surgery 1
• Proceed to Step 4 1

Step 4: Assess Functional Capacity

Determine if the patient can achieve >4 METs (metabolic equivalents) during daily activities: 1

Good functional capacity (>4 METs - able to climb ≥2 flights of stairs): 1, 4

• Perioperative management is unlikely to change based on test results, regardless of surgical procedure 1
• Even with clinical risk factors present, refer patient for surgery 1
• For vascular surgery patients, initiate statin therapy 1
• Continue medications as recommended in Step 3 1

Poor functional capacity (<4 METs): 1

• Proceed to Step 5 1

Step 5: Re-evaluate Surgical Risk in Patients with Poor Functional Capacity

For intermediate-risk surgery: 1

• Proceed to surgery 1
• In patients with ≥1 clinical risk factor, obtain baseline ECG to monitor perioperative changes 1
• Non-invasive stress testing may be considered if results would change management 1

For high-risk surgery: 1

• Proceed to Step 6 1

Step 6: Count Clinical Risk Factors

Clinical risk factors include: 1

• Ischemic heart disease
• Heart failure
• Cerebrovascular disease
• Diabetes mellitus requiring insulin
• Chronic kidney disease (creatinine >2 mg/dL)

<2 risk factors: 1

• Rest echocardiography and biomarkers may be considered for LV function evaluation and prognostic information 1

≥3 risk factors: 1

• Consider non-invasive stress testing 1
• Testing can also guide patient counseling and changes in perioperative management regarding surgery type and anesthesia technique 1

Step 7: Interpret Non-invasive Test Results

If extensive stress-induced ischemia is detected: 1

• Individualized perioperative management is recommended 1
• Consider potential benefit of surgery versus predicted adverse outcome 1
• Evaluate effect of medical therapy and/or coronary revascularization 1

Specific Perioperative Medical Management

Beta-Blocker Therapy

Continue beta-blockers in all patients already taking them for angina, arrhythmias, hypertension, or heart failure throughout the perioperative period 2, 3

For new initiation in patients with known ischemic heart disease or myocardial ischemia: 1, 2, 3

• Start between 30 days and minimum of 2 days before surgery 1
• Begin with low dose and slowly up-titrate 1
• Target resting heart rate of 60-70 bpm with systolic blood pressure >100 mmHg 1
• Continue postoperatively 1

Critical caveat: High-dose beta-blockers (e.g., 100 mg metoprolol succinate) started 2-4 hours before surgery increase stroke risk (1.0% vs 0.5%; P=0.005) and mortality (3.1% vs 2.3%; P=0.03) and should NOT be used 1, 4

Statin Therapy

Initiate statin therapy in patients undergoing vascular surgery 1, 2, 3

Continue statins in patients already taking them 2, 4

ACE Inhibitors/ARBs

In patients with heart failure and systolic LV dysfunction (LVEF <40%), ACE inhibitors (or ARBs if intolerant) should be considered before surgery 1

Aspirin Management

Discontinuation of aspirin should be considered in patients where hemostasis is difficult to control during surgery 1

Routine perioperative low-dose aspirin (100 mg/d) does not decrease cardiovascular events but increases surgical bleeding 4

Continuation or discontinuation should be individualized based on perioperative bleeding risk versus thrombotic risk 1

Timing of Surgery After Coronary Interventions

Balloon angioplasty: Surgery can be performed >2 weeks after intervention with continuation of aspirin 1

Bare-metal stent: Surgery can be performed >4 weeks after intervention; dual antiplatelet therapy should be continued for at least 4 weeks 1

Drug-eluting stent: Surgery can be performed within 6 months for new-generation DES and within 12 months for old-generation DES 1

Management of Severe Aortic Stenosis

Symptomatic patients with severe aortic stenosis scheduled for elective non-cardiac surgery: 1, 5

• Aortic valve replacement is recommended if not at high risk for valve surgery 1, 5
• If high risk for valve surgery, consider TAVI or balloon aortic valvuloplasty 1, 5

Asymptomatic patients with severe aortic stenosis: 1, 5

• Low to intermediate-risk surgery can be performed safely 1
• For high-risk surgery, consider aortic valve replacement if not at high risk for valve surgery 1, 5

Intraoperative Management

Use volatile anesthetic agents (particularly sevoflurane) due to cardioprotective effects 2, 3

Consider neuroaxial anesthesia when not contraindicated, as it reduces perioperative mortality and morbidity by 29% compared to general anesthesia 2

Maintain normothermia to reduce perioperative cardiac events 3

Postoperative Management

Measure high-sensitivity troponin and natriuretic peptides after surgery in high-risk patients for improved risk stratification 2, 3

Consider neuroaxial analgesia for postoperative pain when not contraindicated 2

High-Risk Populations Requiring Special Attention

Adults aged ≥75 years have higher risk of perioperative MI and major adverse cardiovascular events (9.5% vs 4.8% for younger adults; P<0.001) 4

Patients with coronary stents have substantially elevated risk (8.9% vs 1.5% for those without stents; P<0.001) 4

Key Pitfalls to Avoid

• Do not perform routine coronary revascularization to reduce perioperative risk - it should only be done for indications independent of planned surgery 4
• Do not routinely perform preoperative cardiac testing in low-risk patients - it is time and cost-consuming without improving outcomes 6
• Do not start high-dose beta-blockers immediately before surgery - this increases stroke and mortality risk 1, 4
• Do not use beta-adrenergic agonists in patients with severe aortic stenosis - they worsen hemodynamics 5