2014 ESC/ESA Guidelines on Non-cardiac Surgery: Cardiovascular Assessment and Management

Conclusions:

The following are 10 points to remember from the 2014 European Society of Cardiology (ESC) and the European Society of Anaesthesiology (ESA) Guidelines on Non-cardiac Surgery:

1. Surgical interventions (both open and endovascular procedures) are divided into low-risk, intermediate-risk, and high-risk groups with estimated 30-day cardiac event rates of <1%, 1-5%, and >5%.

2. Several risk indices for predicting the risk of perioperative cardiac complications have been developed over the past 30 years. The “revised cardiac index” (consisting of the following six variables: type of surgery, history of ischemic heart disease, history of heart failure, history of cerebrovascular disease, preoperative treatment with insulin, and preoperative creatinine >2.0 mg/dl) has been used for several years. A newer predictive model to estimate the risk of intraoperative/postoperative myocardial infarction or cardiac arrest is the National Surgical Quality Improvement Program (NSQIP) risk calculator, based on the following predictors: type of surgery, functional status, elevated creatinine >1.5 mg/dl, and American Society of Anesthesiologists (ASA) class. The NSQIP model or the Lee risk index are recommended for perioperative risk stratification (Class I, Level of Evidence: B).

3. Noninvasive testing for the detection or evaluation of ischemic heart disease should only be performed if the results might influence perioperative management. Imaging stress testing is recommended before high-risk surgery in patients with more than two clinical risk factors and poor functional capacity of <4 METs (Class I, Level of Evidence: C).

4. The only Class I indication for perioperative beta-blocker therapy is for perioperative continuation of beta-blockers in patients currently receiving this medication (Class I, Level of Evidence: B).

5. Although preoperative initiation of beta-blockers may be considered in patients scheduled for high-risk surgery and who have ≥2 clinical risk factors or ASA status ≥3 (patient with severe systemic disease), this is not recommended without dose titration. The guideline writing committee cautions against overtreatment with fixed high doses, and suggests initiation of therapy at least 1 week and up to 30 days before surgery.

6. Drawing on evidence that beta1-selective blockers without intrinsic sympathomimetic activity are favorable in the perioperative setting, the guideline writing committee explicitly recommends consideration of atenolol or bisoprolol as a first choice when oral beta-blockade is initiated in patients who undergo non-cardiac surgery (Class IIb, Level of Evidence: B).

7. Perioperative continuation of statin therapy is recommended (Class I, Level of Evidence: C), although preoperative initiation of statin therapy should be limited to those undergoing vascular surgery and ideally at least 2 weeks before such surgery (Class IIa, Level of Evidence: B).

8. Although the routine use of aspirin in patients undergoing non-cardiac surgery is not recommended, it is uncertain whether patients with a low perioperative bleeding risk and a high risk of thromboembolic events could benefit from low-dose aspirin. The decision to use low-dose aspirin in patients undergoing non-cardiac surgery, accordingly, should be individualized (Class IIb, Level of Evidence: B).

9. As there are emerging data to suggest that the risk of stent thrombosis in the newer generation drug-eluting stents stabilizes after 6 months, consideration may be given to elective non-cardiac surgery after drug-eluting stent implantation after 6 months in patients who have received such new-generation stents (Class II, Level of Evidence: B).

10. In symptomatic patients with aortic valve stenosis, aortic valve replacement should be considered before elective surgery, provided that they are not at high risk of adverse outcomes from valvular surgery (Class I, Level of Evidence: B). For those patients at high surgical risk or when surgical aortic valve replacement is contraindicated, consideration should be given to balloon aortic valvuloplasty or, preferably, transcatheter aortic valve implantation.

Perspective:

There are important updates to the 2014 ESC/ESA Guidelines on Non-cardiac Surgery, with some notable differences compared to the 2014 American College of Cardiology (ACC)/American Heart Association (AHA) Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Non-cardiac Surgery. Although the ACC/AHA guidelines collapsed the categorization of risk associated with a particular surgery or procedure into low (<1%) or elevated (≥1%), the ESC/ESA Guidelines continue to classify procedures as low-, intermediate-, or high risk. There is less enthusiasm for the use of beta-blockade and the only Class I indication in both guidelines is for the continuation of such therapy in patients who have received beta-blockade chronically. The ESC/ESA guidelines make an explicit recommendation for the use of atenolol or bisoprolol, when beta-blockade is initiated preoperatively. Both guidelines caution against fixed, high-dose regimens that may lead to hypotension and/or bradycardia. The ESC/ESA guidelines are a bit more restrictive with the recommendation for the initiation of statin therapy perioperatively only to those undergoing vascular surgery; both guidelines recommend the continued use of chronic statin therapy. Last, both guideline writing committees recognize that the risk of stent thrombosis seems to stabilize after 6 months following implantation of a second-generation drug-eluting stent, and suggest that dual antiplatelet therapy may accordingly be interrupted after 180 days for elective, non-cardiac surgery in select circumstances.

Clinical Topics: Arrhythmias and Clinical EP, Cardiac Surgery, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Implantable Devices, SCD/Ventricular Arrhythmias, Aortic Surgery, Cardiac Surgery and Arrhythmias, Cardiac Surgery and Heart Failure, Acute Heart Failure

Keywords: Myocardial Infarction, Myocardial Ischemia, Endovascular Procedures, Drug-Eluting Stents, Hypotension, Risk Factors, Insulins, Heart Arrest, Creatinine, Sympathomimetics, Quality Improvement, Thrombosis, Heart Failure, Bradycardia, Bisoprolol, Cardiac Surgical Procedures


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