ESC guidelines on cardiovascular assessment and management of patients undergoing non-cardiac surgery: a practical guide for clinicians

In 2022 European Society of Cardiology (ESC) released the new guidelines on cardiovascular (CV) assessment and management of patients undergoing non-cardiac surgery, which are substantially a deeply revised version of 2014 guidelines (1, 2). The increasing aging of the world's population and the rising burden of CV disease lead clinicians to evaluate on daily basis patients at high risk of developing CV complications in the perioperative setting. Such complication may particularly occur in patients with significant coronary artery disease (CAD), myocardial dysfunction, valvular heart disease (VHD) and arrhythmias. In addition, the type and duration of surgery are critical in stratifying each patient peri-operative risk, as any surgery carries a specific hemodynamic stress and hemorrhagic risk. When concerning peri-operative risk of myocardial ischemia, three leading mechanisms have been pointed out: oxygen supply-demand mismatch due to perioperative fluctuating coronary perfusion on top of noncritical coronary artery disease (type II myocardial infarction); stress induced atherosclerotic plaque erosion/rupture and thrombosis due to surgical-related prothrombotic and inflammatory state (type I myocardial infarction); stent thrombosis in patient with recent history of percutaneous coronary intervention (PCI) due to anti-platelet therapy interruption for preventing surgical-associated bleeding. These guidelines are aimed to help clinicians in standardizing an evidence-based approach to perioperative CV management, to reduce CV morbidity and mortality. A stepwise assessment of patient`s clinical risk factors and test-results, combined with a careful evaluation of the specific surgery-related risk, leads to a tailored risk stratification for each patient, thus allowing to the best preventive/therapeutic strategy before, during and after non-cardiac surgery (NCS). Clinical risk evaluation The first step involves the assessment of surgery-related risk and patient-related risk. All surgical operations are classified into 3 classes of risk: low, intermediate and high, according to 30-day risk of CV death, myocardial infarction (MI) and stroke (<1% for low, 1-5% for intermediate, >5% for high risk). Another crucial issue to be considered is the timing of surgery. If the surgery is deemed emergent or urgent, cardiac testing is not feasible but close follow-up after the intervention is advisable. In case of time-dependent surgery, the decision of performing individualized cardiac testing is taken by a multidisciplinary team on a case-by-case basis. Type and modalities of cardiac testing before elective surgery is closely related to patient characteristics, symptoms and risk profile. In patients aged 45-65 years without history of CV disease, without CV risk factors and without signs and/or symptoms of cardiac disease (e.g. chest pain, dyspnea, peripheral edema, etc) ECG and biomarkers (high sensitivity cardiac troponin I/T and/or BNP/NTproBNP) should be considered prior to high-risk surgery and 24h and 48h afterwards. Otherwise, in patients aged >65 years, with CV risk factors or established CV disease, these exams are recommended also in case of intermediate-risk surgery. In case of abnormal findings on clinical examination or on ECG or laboratory tests, as well as in all symptomatic patients, regardless of risk category, transthoracic echocardiography (TTE) should be performed followed by further examinations if indicated (e.g. imaging or functional tests to rule-out CAD) before NCS.