ESC 2022 2022 ESC Guidelines on cardiovascular assessment and management of patients undergoing non-cardiac surgery
European Society of Cardiology｜循環器 / 周術期｜99 ページ｜チャンク 955｜推奨 191 件｜current
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| 頁 | クラス | レベル | 推奨文 | 表 |
|---|---|---|---|---|
| p.18 | IIa | B | Endovascular or video-assisted procedures should be considered for patients with high CV risk undergoing vascular or pulmonary surgery.21,35–39 CV, cardiovascular. aClass of recommendation. bLevel of evidence. | Recommendation Table 1 — Recommendations for selection of surgical approach and impact on risk |
| p.20 | I | C | In all patients scheduled for NCS, an accurate history and clinical examination are recommended. | Recommendation Table 2 — Recommendations for all patients scheduled for non-cardiac surgery |
| p.20 | I | B | It is recommended to perform a pre-operative risk assessment, ideally at the same time as the NCS is proposed.46–53 | Recommendation Table 2 — Recommendations for all patients scheduled for non-cardiac surgery |
| p.20 | I | C | If time allows, it is recommended to optimize guideline-recommended treatment of CVD and CV risk factors before NCS. | Recommendation Table 2 — Recommendations for all patients scheduled for non-cardiac surgery |
| p.20 | I | C | In patients with a family history of genetic cardiomyopathy, it is recommended to perform an ECG and TTE before NCS, regardless of age and symptoms. | Recommendation Table 3 — Recommendations for patients aged ,65 years without signs, symptoms, or history of cardiovascular disease |
| p.20 | IIa | C | In patients aged 45–65 years without signs, symptoms, or history of CVD, ECG and biomarkers should be considered before high-risk NCS. | Recommendation Table 3 — Recommendations for patients aged ,65 years without signs, symptoms, or history of cardiovascular disease |
| p.20 | I | C | Newly detected murmur In patients with a newly detected murmur and symptoms or signs of CVD, TTE is recommended before NCS. | Recommendation Table 4 — Recommendations for pre-operative assessment in patients with previously unknown murmur, angina, dyspnoea, or peripheral oedema |
| p.21 | I | C | In patients with a newly detected murmur suggesting clinically significant pathology, TTE is recommended before high-risk NCS. | |
| p.21 | IIa | C | In patients with a newly detected murmur, but without other signs or symptoms of CVD, TTE should be considered before moderate-risk NCS. Previously unknown angina | |
| p.21 | I | C | If a patient scheduled for elective NCS has chest pain or other symptoms suggestive of undetected CAD, further diagnostic work-up before NCS is recommended. | |
| p.21 | I | C | If a patient in need of acute NCS also has chest pain or other symptoms suggestive of undetected CAD, a multidisciplinary assessment approach is recommended to choose the treatment with lowest total risk for the patient. | |
| p.21 | I | C | Dyspnoea and/or peripheral oedema In patients with dyspnoea and/or peripheral oedema, an ECG and an NT-proBNP/BNP test is indicated before NCS, unless there is a certain non-cardiac explanation. | |
| p.21 | I | C | In patients with dyspnoea and/or peripheral oedema and elevated NT-proBNP/BNP, TTE is recommended before NCS.c | |
| p.22 | I | C | It is recommended to give patients individualized instructions for pre-operative and post-operative changes in medication, in verbal and written formats with clear and concise directions. | Recommendation Table 5 — Recommendations for patient information |
| p.22 | IIa | C | It should be considered to set up a structured information list (e.g. a check list to help with common issues) for patients with CVD or at high risk of CV complications scheduled for NCS. | Recommendation Table 5 — Recommendations for patient information |
| p.24 | IIa | B | In patients aged ≥70 years and scheduled to undergo intermediate- or high-risk NCS, frailty screening should be considered using a validated screening tool.84–87,90,91 | Recommendation Table 6 — Recommendations for pre-operative assessment of frailty and functional capacity |
| p.25 | IIa | B | Adjusting risk assessments according to self-reported ability to climb two flights of stairs should be considered in patients referred for intermediate- or high-risk NCS.94 NCS, non-cardiac surgery. aClass of recommendation. bLevel of evidence. | |
| p.26 | I | C | In patients who have known CVD or CV risk factors (including age ≥65 years), or symptoms or signs suggestive of CVD it is recommended to obtain a pre-operative 12-lead ECG before intermediate- and high-risk NCS.97–99 | Recommendation Table 7 — Recommendations for pre-operative risk assessment—electrocardiography and biomarkers |
| p.26 | I | B | In patients who have known CVD, CV risk factors (including age ≥65 years), or symptoms suggestive of CVD it is recommended to measure hs-cTn T or hs-cTn I before intermediate- and high-risk NCS, and at 24 h and 48 h afterwards.53,105–107,109–111,117 | Recommendation Table 7 — Recommendations for pre-operative risk assessment—electrocardiography and biomarkers |
| p.26 | IIa | B | In patients who have known CVD, CV risk factors (including age ≥65 years), or symptoms suggestive of CVD, it should be considered to measure BNP or NT-proBNP before intermediate- and high-risk NCS.52,104,112–114 | |
| p.26 | III | B | In low-risk patients undergoing low- and intermediate-risk NCS, it is not recommended to routinely obtain pre-operative ECG, hs-cTn T/I, or BNP/NT-proBNP concentrations.109,111,117–119 | |
| p.27 | III | C | not recommended.122,145 | Recommendation Table 8 — Recommendations for transthoracic echocardiography |
| p.27 | I | B | TTE is recommended in patients with poor functional capacityc and/or high NT-proBNP/ BNP,d or if murmurs are detected before high-risk NCS, in order to undertake risk-reduction | Recommendation Table 8 — Recommendations for transthoracic echocardiography |
| p.27 | IIa | B | strategies.121,124,127,141–143 TTE should be considered in patients with suspected new CVD or unexplained signs or symptoms before high-risk NCS.59,124,125 | Recommendation Table 8 — Recommendations for transthoracic echocardiography |
| p.27 | IIb | B | TTE may be considered in patients with poor functional capacity, abnormal ECG, high NT-proBNP/BNP,d or ≥1 clinical risk factor before intermediate-risk NCS.126–128 | Recommendation Table 8 — Recommendations for transthoracic echocardiography |
| p.27 | IIb | B | To avoid delaying surgery, a FOCUS exam performed by trained specialists may be considered as an alternative to TTE for pre-operative triage.129,130,132,133,144 Routine pre-operative evaluation of LV function is | Recommendation Table 8 — Recommendations for transthoracic echocardiography |
| p.28 | I | B | Stress imaging is recommended before high-risk elective NCS in patients with poor functional capacityc and high likelihood of CADd or high clinical risk.e,146,156–158 | Recommendation Table 9 — Recommendations for stress imaging |
| p.28 | IIa | C | Stress imaging should be considered before high-risk NCS in asymptomatic patients with poor functional capacity,d and previous PCI or CABG.147 | Recommendation Table 9 — Recommendations for stress imaging |
| p.28 | IIb | B | Stress imaging may be considered before intermediate-risk NCS when ischaemia is of concern in patients with clinical risk factors and | Recommendation Table 9 — Recommendations for stress imaging |
| p.28 | III | C | poor functional capacity.d,152,157,158 Stress imaging is not recommended routinely before NCS. | Recommendation Table 9 — Recommendations for stress imaging |
| p.28 | I | C | It is recommended to use the same indications for ICA and revascularization pre-operatively as in the non-surgical setting.98,146 CCTA should be considered to rule out CAD in | Recommendation Table 10 — Recommendations for coronary angiography |
| p.28 | IIa | C | patients with suspected CCS or biomarker-negative NSTE-ACS in case of low-to-intermediate clinical likelihood of CAD, or in patients unsuitable for non-invasive functional testing undergoing non-urgent, intermediate-, and high-risk NCS. | Recommendation Table 10 — Recommendations for coronary angiography |
| p.29 | IIb | B | CCS patients undergoing elective surgical CEA.172 | |
| p.29 | III | C | Pre-operative ICA may be considered in stable Routine pre-operative ICA is not recommended in stable CCS patients undergoing low- or intermediate-risk NCS. 5 General risk-reduction strategies | |
| p.29 | I | B | Smoking cessation .4 weeks before NCS is recommended to reduce post-operative complications and mortality.181,182 | Recommendation Table 11 — Recommendations for lifestyle and cardiovascular risk factors |
| p.29 | I | B | Control of CV risk factors—including blood pressure, dyslipidaemia, and diabetes—is recommended before NCS.173,176–178,183 CV, cardiovascular; NCS, non-cardiac surgery. aClass of recommendation. bLevel of evidence. | Recommendation Table 11 — Recommendations for lifestyle and cardiovascular risk factors |
| p.31 | III | A | Routine initiation of beta-blocker peri-operatively is not recommended.185,187,189,233,234 | Recommendation Table 12 — Recommendations for pharmacological treatment |
| p.31 | IIa | C | Initiation In patients with an indication for statins, it should be considered to initiate statins peri-operatively. Pre-operative initiation of beta-blockers in | Recommendation Table 12 — Recommendations for pharmacological treatment |
| p.31 | IIb | A | advancec of high-risk NCS may be considered in patients who have two or more clinical risk factors,d in order to reduce the incidence of | Recommendation Table 12 — Recommendations for pharmacological treatment |
| p.31 | IIb | B | peri-operative myocardial infarction.188,190–192 Pre-operative initiation of beta-blocker in advance of NCS may be considered in patients who have known CAD or myocardial ischaemia.e,230–232 | Recommendation Table 12 — Recommendations for pharmacological treatment |
| p.31 | I | B | Continuation Peri-operative continuation of beta-blockers is recommended in patients currently receiving this medication.190,196–199 | Recommendation Table 12 — Recommendations for pharmacological treatment |
| p.31 | I | B | In patients already on statins, it is recommended to continue statins during the peri-operative period.235 | Recommendation Table 12 — Recommendations for pharmacological treatment |
| p.31 | IIb | C | In patients with stable HF, peri-operative continuation of RAAS inhibitors may be considered. | Recommendation Table 12 — Recommendations for pharmacological treatment |
| p.32 | IIa | B | Interruption In patients without HF, withholding RAAS inhibitors on the day of NCS should be considered to prevent peri-operative hypotension.215,216 | |
| p.32 | IIa | B | For patients on diuretics to treat hypertension, transient discontinuation of diuretics on the day of NCS should be considered.236 | |
| p.32 | IIa | C | It should be considered to interrupt SGLT-2 inhibitor therapy for at least 3 days before intermediate- and high-risk NCS. | |
| p.37 | I | A | It is recommended to delay elective NCS until 6 months after elective PCI and 12 months after an ACS.264,271 | Recommendation Table 13 — Recommendations for use of antiplatelet therapy in patients undergoing noncardiac surgery |
| p.37 | I | B | After elective PCI, it is recommended to delay time-sensitive NCS until a minimum of 1 month of DAPT treatment has been given.266,271,288,289 | Recommendation Table 13 — Recommendations for use of antiplatelet therapy in patients undergoing noncardiac surgery |
| p.37 | I | C | In patients with a recent PCI scheduled for NCS, it is recommended that management of antiplatelet therapy is discussed between the surgeon, anaesthesiologist, and cardiologist. | Recommendation Table 13 — Recommendations for use of antiplatelet therapy in patients undergoing noncardiac surgery |
| p.37 | IIa | C | In high-risk patients with a recent PCI (e.g. STEMI patients or high-risk NSTE-ACS patients), a DAPT duration of at least 3 months should be considered before time-sensitive NCS. | Recommendation Table 13 — Recommendations for use of antiplatelet therapy in patients undergoing noncardiac surgery |
| p.37 | I | B | Continuation of medication In patients with a previous PCI, it is recommended to continue aspirin peri-operatively if the bleeding risk allows.244 | Recommendation Table 13 — Recommendations for use of antiplatelet therapy in patients undergoing noncardiac surgery |
| p.37 | I | B | NCS If interruption of P2Y12 inhibitor is indicated, it is recommended to withhold ticagrelor for 3–5 days, clopidogrel for 5 days, and prasugrel for 7 days prior to NCS.262–264 | Recommendation Table 13 — Recommendations for use of antiplatelet therapy in patients undergoing noncardiac surgery |
| p.37 | I | C | For patients undergoing high bleeding risk surgery (e.g. intracranial, spinal neurosurgery, or vitreoretinal eye surgery), it is recommended to interrupt aspirin for at least 7 days pre-operatively. | Recommendation Table 13 — Recommendations for use of antiplatelet therapy in patients undergoing noncardiac surgery |
| p.37 | IIb | B | In patients without a history of PCI, interruption of aspirin at least 3 days before NCS may be considered if the bleeding risk outweighs the ischaemic risk, to reduce the risk of bleeding.243 Resumption of medication | Recommendation Table 13 — Recommendations for use of antiplatelet therapy in patients undergoing noncardiac surgery |
| p.37 | I | C | If antiplatelet therapy has been interrupted before a surgical procedure, it is recommended to restart therapy as soon as possible (within 48 h) post-surgery, according to interdisciplinary risk assessment. | Recommendation Table 13 — Recommendations for use of antiplatelet therapy in patients undergoing noncardiac surgery |
| p.43 | I | C | Interruption of anticoagulation When an urgent surgical intervention is required, it is recommended that NOAC therapy is immediately interrupted. | Recommendation Table 14 — Recommendations for interruption and resumption of anticoagulants in patients undergoing non-cardiac surgery |
| p.43 | IIa | B | Idarucizumab should be considered in patients on dabigatran and requiring urgent surgical intervention with intermediate to high bleeding risk.303 | Recommendation Table 14 — Recommendations for interruption and resumption of anticoagulants in patients undergoing non-cardiac surgery |
| p.43 | I | B | In non-minor bleeding risk procedures in patients using a NOAC, it is recommended to use an interruption regimen based on the NOAC compound, renal function, and bleeding risk.310,311 | |
| p.43 | IIa | C | For interventions with a very high risk of bleeding, such as spinal or epidural anaesthesia, interruption of NOACs for up to five half-lives and re-initiation after 24 h should be considered. | |
| p.43 | IIa | C | When specific reversal agents are unavailable, PCC or activated PCC should be considered for reversing NOAC effects. | |
| p.43 | IIa | C | If an urgent surgical intervention is required, specific coagulation tests and assessment of NOAC plasma levels should be considered to interpret routine coagulation tests and waning of anticoagulant effect. | |
| p.43 | I | B | Continuation of medication In minor bleeding risk surgery and other procedures where bleeding can be easily controlled, it is recommended to perform surgery without interruption of OAC therapy.240,296–299 | |
| p.43 | I | B | LMWH is recommended, as an alternative to UFH, for bridging in patients with MHVs and high surgical risk.295 | |
| p.43 | I | C | In patients using NOACs, it is recommended that minor bleeding risk procedures are performed at trough levels (typically 12–24 h after last intake). For patients with mechanical prosthetic heart | |
| p.43 | IIa | C | valves undergoing NCS, bridging with UFH or LMWH should be considered if OAC interruption is needed and patients have: (i) mechanical AVR and any thromboembolic risk factor; (ii) | |
| p.43 | III | B | old-generation mechanical AVR; or (iii) mechanical mitral or tricuspid valve replacement. Bridging of OAC therapy is not recommended in patients with low/moderate thrombotic risk undergoing NCS.290,292,293,306–308,311 Start/resumption of medication | |
| p.43 | IIb | C | anticoagulation outweighs the risk of thromboembolic events, postponing therapeutic anticoagulation 48–72 h after the procedure may be considered, using post-operative | Recommendation Table 14 — Recommendations for interruption and resumption of anticoagulants in patients undergoing non-cardiac surgery |
| p.43 | III | C | thromboprophylaxis until resumption of full OAC dose is deemed safe. Use of reduced-dose NOAC to attenuate the risk of post-operative bleeding is not recommended. Continued | Recommendation Table 14 — Recommendations for interruption and resumption of anticoagulants in patients undergoing non-cardiac surgery |
| p.44 | I | A | It is recommended that decisions about peri-operative thromboprophylaxis in NCS are based on individual and procedure-specific risk factors.328,332 | Recommendation Table 15 — Recommendations for thromboprophylaxis |
| p.44 | I | A | If thromboprophylaxis is deemed necessary, it is recommended to choose the type and duration of thromboprophylaxis (LMWH, NOAC, or fondaparinux) according to type of NCS, duration of immobilization, and patient-related | Recommendation Table 15 — Recommendations for thromboprophylaxis |
| p.44 | IIa | A | factors.328,332 In patients with a low bleeding risk, peri-operative thromboprophylaxis should be considered for a duration of up to 14 or 35 days, for total knee or hip arthroplasty, respectively.334–337 | Recommendation Table 15 — Recommendations for thromboprophylaxis |
| p.44 | IIb | A | NOACs in thromboprophylaxis dose may be considered as alternative treatments to LMWH after total knee and hip arthroplasty.333 | Recommendation Table 15 — Recommendations for thromboprophylaxis |
| p.45 | I | B | It is recommended to measure haemoglobin pre-operatively in patients scheduled for intermediate- to high-risk NCS.350,354 | Recommendation Table 16 — Recommendations for intra- and post-operative complications associated with anaemia |
| p.45 | I | A | It is recommended to treat anaemia in advance of NCS, in order to reduce the need for RBC transfusion during NCS.357,361 | Recommendation Table 16 — Recommendations for intra- and post-operative complications associated with anaemia |
| p.45 | IIa | C | The use of an algorithm to diagnose and treat anaemic patients before NCS should be considered. NCS, non-cardiac surgery; RBC, red blood cell. aClass of recommendation. bLevel of evidence. | Recommendation Table 16 — Recommendations for intra- and post-operative complications associated with anaemia |
| p.46 | IIa | B | Application of meticulous haemostasis should be considered a routine procedure.350,389 | |
| p.46 | I | A | In patients undergoing surgery with expected blood loss of ≥500 mL, use of washed cell salvage is recommended.377,378 | Recommendation Table 17 — Recommendations for intra- and post-operative complications associated with blood loss |
| p.46 | I | A | It is recommended to use point-of-care diagnostics for guidance of blood component therapy, when available.370,379–383 | Recommendation Table 17 — Recommendations for intra- and post-operative complications associated with blood loss |
| p.46 | IIa | A | In patients undergoing NCS and experiencing major bleeding, administration of tranexamic acid should be immediately considered.375,376,384–386 | |
| p.46 | IIa | B | Use of closed-loop arterial blood sampling systems should be considered to avoid blood loss.366,378,387,388 NCS, non-cardiac surgery. aClass of recommendation. bLevel of evidence. | |
| p.46 | IIa | B | A feedback/monitoring programme or clinical decision support system should be considered to be assessed before blood transfusion.392–396 | Recommendation Table 18 — Recommendations for intra- and post-operative complications associated with allogeneic blood transfusion |
| p.46 | IIa | C | Before allogenic blood transfusion, it should be considered to obtain an extensive consent about risks asssociated with transfusion. aClass of recommendation. bLevel of evidence. 6 Specific diseases | Recommendation Table 18 — Recommendations for intra- and post-operative complications associated with allogeneic blood transfusion |
| p.49 | I | A | Patients with CCS If PCI is indicated before NCS, the use of new-generation DES is recommended over BMS and balloon angioplasty.268 | Recommendation Table 19 — Recommendations for the timing of non-cardiac surgery and revascularization in patients with known coronary artery disease |
| p.49 | IIa | C | Pre-operative evaluation of patients with an indication for PCI by an expert team (surgeon and cardiologist) should be considered before elective NCS. | Recommendation Table 19 — Recommendations for the timing of non-cardiac surgery and revascularization in patients with known coronary artery disease |
| p.49 | IIb | B | Myocardial revascularization before high-risk elective NCS may be considered, depending on the amount of ischaemic myocardium, refractory symptoms, and findings at coronary angiography | Recommendation Table 19 — Recommendations for the timing of non-cardiac surgery and revascularization in patients with known coronary artery disease |
| p.49 | III | B | (as in the case of left main disease).399,402,403 Routine myocardial revascularization before low- and intermediate-risk NCS in patients with CCS is not recommended.399,400 Patients with ACS | Recommendation Table 19 — Recommendations for the timing of non-cardiac surgery and revascularization in patients with known coronary artery disease |
| p.49 | I | A | If NCS can safely be postponed (e.g. at least 3 months), it is recommended that patients with ACS being scheduled for NCS undergo diagnostic and therapeutic interventions as recommended for ACS patients in general.98,268 | Recommendation Table 19 — Recommendations for the timing of non-cardiac surgery and revascularization in patients with known coronary artery disease |
| p.49 | IIa | C | In the unlikely combination of a life-threatening clinical condition requiring urgent NCS, and NSTE-ACS with an indication for revascularization, the priorities for surgery on a case-by-case basis should be considered by the expert team.268 | Recommendation Table 19 — Recommendations for the timing of non-cardiac surgery and revascularization in patients with known coronary artery disease |
| p.50 | I | B | In patients with suspected or known HF scheduled for high-risk NCS, it is recommended to evaluate LV function with echocardiography and measurement of NT-proBNP/BNP levels, unless this has recently been performed.112,113,422,423 | Recommendation Table 20 — Recommendations for management of heart failure in patients undergoing non-cardiac surgery |
| p.50 | I | A | It is recommended that patients with HF undergoing NCS receive optimal medical treatment according to current ESC guidelines.412 | Recommendation Table 20 — Recommendations for management of heart failure in patients undergoing non-cardiac surgery |
| p.50 | I | C | In patients with HF undergoing NCS, it is recommended to regularly assess volume status and signs of organ perfusion. | Recommendation Table 20 — Recommendations for management of heart failure in patients undergoing non-cardiac surgery |
| p.50 | I | C | A multidisciplinary team including VAD specialists is recommended for peri-operative management of patients with HF receiving mechanical circulatory support. | Recommendation Table 20 — Recommendations for management of heart failure in patients undergoing non-cardiac surgery |
| p.53 | I | C | Clinical and echocardiographic evaluation (if not recently performed) is recommended in all patients with known or suspected VHD who are scheduled for elective intermediate- or high-risk NCS. | Recommendation Table 21 — Recommendations for management of valvular heart disease in patients undergoing non-cardiac surgery |
| p.53 | I | C | Aortic valve stenosis AVR (SAVR or TAVI) is recommended in symptomatic patients with severe AS who are scheduled for elective intermediate- or high-risk NCS. | Recommendation Table 21 — Recommendations for management of valvular heart disease in patients undergoing non-cardiac surgery |
| p.53 | IIa | C | In asymptomatic patients with severe AS who are scheduled for elective high-risk NCS, AVR (SAVR or TAVI) should be considered after Heart Team discussion. | |
| p.53 | IIb | C | In patients with severe symptomatic AS in need of time-sensitive NCS or in whom the TAVI and SAVR are unfeasible, BAV may be considered before NCS as a bridge to definitive aortic valve repair. Aortic valve regurgitation | |
| p.53 | I | C | In patients with symptomatic severe AR or asymptomatic severe AR and LVESD .50 mm or LVESDi (LVESD/BSA) .25 mm/m2 (in patients with small body size) or resting LVEF ≤50%, valve surgery is recommended prior to elective intermediate- or high-risk NCS. | |
| p.53 | I | C | Mitral valve stenosis In patients with moderate-to-severe rheumatic MS and symptoms or SPAP .50 mmHg, valve intervention (PMC or surgery) is recommended before elective intermediate- or high-risk NCS. Mitral valve regurgitation | |
| p.53 | IIa | C | In patients with symptomatic severe primary MR or asymptomatic severe primary MR with LV dysfunction (LVESD ≥40 mm and/or LVEF ≤60%), valve intervention (surgical or transcatheter) should be considered prior to intermediate- or high-risk NCS, if time allows. | |
| p.53 | IIa | C | In patients with severe secondary MR who remain symptomatic despite guideline-directed medical therapy (including CRT if indicated), valve intervention (transcatheter or surgical) should be considered before NCS, in eligible patients with an acceptable procedural risk. | |
| p.55 | I | C | Supraventricular arrhythmias In patients with SVT controlled by medication, it is recommended that AADs are continued during the peri-operative period. | Recommendation Table 22 — Recommendations for management of known or newly diagnosed arrhythmias |
| p.55 | IIa | B | Ablation should be considered in symptomatic patients with recurrent or persistent SVT, despite treatment, prior to high-risk, non-urgent NCS.437–441 | Recommendation Table 22 — Recommendations for management of known or newly diagnosed arrhythmias |
| p.55 | I | B | In AF patients with acute or worsening haemodynamic instability undergoing NCS, emergency electrical cardioversion is recommended.99,472,473 | Recommendation Table 22 — Recommendations for management of known or newly diagnosed arrhythmias |
| p.55 | IIb | B | In AF patients with haemodynamic instability, amiodarone may be considered for acute control of heart rate.99 | Recommendation Table 22 — Recommendations for management of known or newly diagnosed arrhythmias |
| p.56 | I | B | Ventricular arrhythmias In patients with symptomatic, monomorphic, sustained VT associated with myocardial scar, recurring despite optimal medical therapy, ablation of arrhythmia is recommended before | |
| p.56 | III | C | elective NCS.474–480 It is not recommended to initiate treatment of asymptomatic PVC during NCS. | |
| p.57 | IIa | C | If indications for pacing exist according to the 2021 ESC Guidelines on cardiac pacing and cardiac resynchronization therapy,481 NCS surgery should be deferred and implantation of a permanent pacemaker should be considered. It is recommended that patients with temporarily | Recommendation Table 23 — Recommendations for management of bradyarrhythmia and patients carrying cardiac implantable devices |
| p.57 | I | C | deactivated ICDs have continuous ECG monitoring, and during the peri-operative period are accompanied by personnel skilled in early detection and treatment of arrhythmias. In high-risk patients (e.g. pacemaker-dependant or ICD patients), or if access to the torso will be difficult during the procedure, it is recommended to place transcutaneous pacing/defibrillation pads | Recommendation Table 23 — Recommendations for management of bradyarrhythmia and patients carrying cardiac implantable devices |
| p.57 | I | C | prior to NCS. It is recommended that all patients with CIEDs that are reprogrammed before surgery have a re-check and necessary reprogramming as soon as possible after the procedure. | Recommendation Table 23 — Recommendations for management of bradyarrhythmia and patients carrying cardiac implantable devices |
| p.57 | IIa | C | In high-risk CIED patients (e.g. with ICD or being pacing-dependant) undergoing NCS carrying a high probability of electromagnetic interference (e.g. involving unipolar electrosurgery above the umbilical area), CIED check-up and necessary reprogramming immediately before the procedure should be considered. | |
| p.58 | I | C | In patients with ACHD, a consultation with an ACHD specialist is recommended before intermediate- or high-risk surgery. | Recommendation Table 24 — Recommendations for management of patients with adult congenital heart disease undergoing non-cardiac surgery |
| p.58 | I | C | In patients with ACHD, it is recommended that intermediate- and high-risk elective surgery is performed in a centre with experience in the care of ACHD patients. ACHD, adults with congenital heart disease. aClass of recommendation. bLevel of evidence. | Recommendation Table 24 — Recommendations for management of patients with adult congenital heart disease undergoing non-cardiac surgery |
| p.59 | IIa | C | In patients with acute pericarditis, deferring elective NCS until complete resolution of the underlying process should be considered. | Recommendation Table 25 — Recommendations for pericardial diseases |
| p.59 | IIb | C | Avoiding elective NCS procedures under general anaesthesia until colchicine or the immunosuppressive treatment course for pericardial disease is completed may be considered. NCS, non-cardiac surgery. aClass of recommendation. bLevel of evidence. | Recommendation Table 25 — Recommendations for pericardial diseases |
| p.60 | I | C | Surgery-related peri-operative risk factors in It is recommended to continue chronic therapy for PAH in the peri-operative phase of NCS. patients with PAH | Recommendation Table 26 — Recommendations for patients with pulmonary arterial hypertension undergoing non-cardiac surgery |
| p.60 | I | C | • Emergency surgery It is recommended that haemodynamic • Duration of anaesthesia .3 h • Intra-operative requirement for monitoring of patients with severe PAH continues for at least 24 h in the post-operative period. vasopressors In the case of progression of right HF in the | Recommendation Table 26 — Recommendations for patients with pulmonary arterial hypertension undergoing non-cardiac surgery |
| p.60 | I | C | post-operative period in patients with PAH, it is recommended that the diuretic dose be © ESC 2022 optimized and, if necessary, i.v. prostacyclin analogues be initiated under the guidance of a physician experienced in the management of PAH. | Recommendation Table 26 — Recommendations for patients with pulmonary arterial hypertension undergoing non-cardiac surgery |
| p.60 | IIa | C | Inodilator drugs (dobutamine, milrinone, levosimendan), which increase cardiac output and lower pulmonary vascular resistance, should be considered peri-operatively according to the haemodynamic status of the patient. | Recommendation Table 26 — Recommendations for patients with pulmonary arterial hypertension undergoing non-cardiac surgery |
| p.61 | I | A | In patients with chronic hypertension undergoing elective NCS, it is recommended to avoid large peri-operative fluctuations in blood pressure, particularly hypotension, during the peri-operative period.528,531 | Recommendation Table 27 — Recommendations for pre-operative management of hypertension |
| p.61 | I | C | It is recommended to perform pre-operative screening for hypertension-mediated organ damage and CV risk factors in newly diagnosed hypertensive patients who are scheduled for | Recommendation Table 27 — Recommendations for pre-operative management of hypertension |
| p.61 | III | C | elective high-risk NCS. It is not recommended to defer NCS in patients with stage 1 or 2 hypertension. CV, cardiovascular; NCS, non-cardiac surgery. aClass of recommendation. bLevel of evidence. | Recommendation Table 27 — Recommendations for pre-operative management of hypertension |
| p.62 | I | C | In patients with poor functional capacity or significant risk factors or symptoms (such as moderate-to-severe angina pectoris, decompensated HF, valvular disease, and significant arrhythmia), referral for cardiac | Recommendation Table 28 — Recommendations for management of patients with peripheral artery disease and/or abdominal aortic aneurysm undergoing non-cardiac surgery |
| p.62 | III | C | work-up and optimization is recommended prior to elective surgery for PAD or AAA. Routine referral for cardiac work-up, coronary angiography, or CPET prior to elective surgery for PAD or AAA is not recommended. | Recommendation Table 28 — Recommendations for management of patients with peripheral artery disease and/or abdominal aortic aneurysm undergoing non-cardiac surgery |
| p.62 | I | C | Pre-operative carotid artery and cerebral imaging is recommended in patients with a history of TIA or stroke in the previous 6 months and who have not undergone ipsilateral revascularization. | Recommendation Table 29 — Recommendations for management of patients with suspected or established carotid artery disease undergoing non-cardiac surgery |
| p.62 | IIa | C | For patients with carotid artery disease undergoing NCS, the same indications for carotid revascularization should be considered as for | Recommendation Table 29 — Recommendations for management of patients with suspected or established carotid artery disease undergoing non-cardiac surgery |
| p.62 | III | C | other patients with carotid stenosis. Pre-operative carotid artery imaging is not recommended routinely in patients undergoing NCS. NCS, non-cardiac surgery; TIA, transient ischaemic attack. aClass of recommendation. bLevel of evidence. © ESC 2022 | Recommendation Table 29 — Recommendations for management of patients with suspected or established carotid artery disease undergoing non-cardiac surgery |
| p.63 | IIa | B | In patients with renal disease requiring peri-operative contrast-enhanced radiography, balanced hydration with i.v. isotonic fluids, the use of a minimal volume of contrast media, and the use of low-osmolar or iso-osmolar contrast media should be considered.547,553–555 | Recommendation Table 30 — Recommendations for management of patients with renal disease undergoing non-cardiac surgery |
| p.63 | I | C | In patients with known risk factors (age .65 years, BMI .30 kg/m2, diabetes, hypertension, hyperlipidaemia, CV disease, or smoking) undergoing intermediate- or high-risk NCS, it is recommended to screen for pre-operative renal | Recommendation Table 30 — Recommendations for management of patients with renal disease undergoing non-cardiac surgery |
| p.63 | IIa | C | disease by measuring serum creatinine and GFR. If a cystatin C measurement assay is available, cystatin C measurement should be considered in patients with impaired eGFR (,45–59 mL/min/ 1.73 m2) to confirm kidney disease.556 | Recommendation Table 30 — Recommendations for management of patients with renal disease undergoing non-cardiac surgery |
| p.63 | I | B | © ESC 2022 It is recommended to assess cardiorespiratory fitness to estimate peri-operative CV risk in obese patients, with particular attention to those undergoing intermediate- and high-risk NCS.565,570 | Recommendation Table 31 — Recommendations for management of patients with obesity undergoing noncardiac surgery |
| p.63 | IIa | C | In patients at high risk of obesity hypoventilation syndrome, additional specialist investigation before major elective NCS should be considered.516 CV, cardiovascular; NCS, non-cardiac surgery. aClass of recommendation. bLevel of evidence. | Recommendation Table 31 — Recommendations for management of patients with obesity undergoing noncardiac surgery |
| p.64 | I | B | In patients with diabetes or disturbed glucose metabolism, a pre-operative HbA1c test is recommended, if this measurement has been not performed in the previous 3 months. In case of HbA1c ≥8.5% (≥69 mmol/mol), elective NCS should be postponed, if safe and practical.578–581 | Recommendation Table 32 — Recommendations for management of patients with diabetes mellitus undergoing non-cardiac surgery |
| p.64 | I | C | A pre-operative assessment for concomitant cardiac conditions (see Sections 3 and 4) is recommended in patients with diabetes with suspected or known CAD, and those with autonomic neuropathy, retinopathy, or renal disease and scheduled to undergo intermediateor high-risk NCS. | |
| p.68 | I | A | In order to preserve optimal CV stability, it is recommended to apply goal-directed haemodynamic therapy in patients undergoing high-risk NCS.614–618 It is recommended to avoid post-operative acute | Recommendation Table 33 — Recommendations for peri-operative monitoring and anaesthesia |
| p.68 | I | B | In order to minimize the risk of post-operative organ dysfunction, it is recommended to avoid an intra-operative mean arterial pressure decrease of .20% from baseline values or ,60–70 mmHg for | Recommendation Table 33 — Recommendations for peri-operative monitoring and anaesthesia |
| p.68 | III | B | ≥10 min.214,600–602,634 Non-aspirin NSAIDs are not recommended as first-line analgesics in patients with established or high risk of CVD.633,635 | Recommendation Table 33 — Recommendations for peri-operative monitoring and anaesthesia |
| p.74 | I | B | It is recommended to have high awareness of peri-operative CV complications, combined with surveillance for PMI in patients undergoing intermediate- or high-risk NCS.41,101,109– 111,118,413,636–639 | Recommendation Table 34 — Recommendations for peri-operative cardiovascular complications |
| p.74 | I | B | Systematic PMI work-up is recommended to identify the underlying pathophysiology and define therapy.41,101,109–111,118,413,636–639 | Recommendation Table 34 — Recommendations for peri-operative cardiovascular complications |
| p.74 | I | C | It is recommended to treat post-operative STEMI, NSTE-ACS, acute HF, and tachyarrhythmias in accordance with guidelines for the non-surgical setting, after interdisciplinary discussion with the surgeon about bleeding risk.98,99,171,651,652 | Recommendation Table 34 — Recommendations for peri-operative cardiovascular complications |
| p.74 | I | C | In patients with post-operative PE of high or intermediate clinical probability, initiation of anticoagulation is recommended without delay, while diagnostic work-up is in progress, if bleeding | Recommendation Table 34 — Recommendations for peri-operative cardiovascular complications |
| p.74 | I | C | risk is low.650,652 Post-operative oral anticoagulation for PE is recommended to be administered for a period of at least 3 months.99,650 | Recommendation Table 34 — Recommendations for peri-operative cardiovascular complications |
| p.74 | I | A | In patients with a post-operative indication for OAC, NOAC is generally recommended over VKA.99 | Recommendation Table 34 — Recommendations for peri-operative cardiovascular complications |
| p.74 | IIa | B | In patients with post-operative AF after NCS, long-term OAC therapy should be considered in all patients at risk of stroke, considering the anticipated net clinical benefit of OAC therapy, | Recommendation Table 34 — Recommendations for peri-operative cardiovascular complications |
| p.74 | IIb | B | and informed patient preferences.99,682,683,685,686 In patients with MINS and at low risk of bleeding, treatment with dabigatran 110 mg orally b.i.d. may be considered from ≏1 week after NCS.650 | Recommendation Table 34 — Recommendations for peri-operative cardiovascular complications |
| p.75 | III | B | Routine use of beta-blocker for the prevention of post-operative AF in patients undergoing NCS is not recommended.185,201 9 Key messages | |
| p.76 | I | C | In all patients scheduled for NCS, an accurate history and clinical examination are recommended. | |
| p.76 | I | B | It is recommended to perform a pre-operative risk assessment, ideally at the same time as the NCS is proposed. | |
| p.76 | I | C | If time allows, it is recommended to optimize guideline-recommended treatment of CVD and CV risk factors before NCS. | |
| p.76 | I | C | In patients with a newly detected murmur and symptoms or signs of CVD, TTE is recommended before NCS. | |
| p.76 | I | C | In patients with a newly detected murmur suggesting clinically significant pathology, TTE is recommended before high-risk NCS. | |
| p.77 | I | C | In patients with dyspnoea and/or peripheral oedema and elevated NT-proBNP/BNP, TTE is recommended before NCS. | |
| p.77 | I | C | It is recommended to use the same indications for ICA and revascularization pre-operatively as in the non-surgical setting. | |
| p.77 | III | C | Routine pre-operative evaluation of LV function is not recommended. | |
| p.77 | III | C | Stress imaging is not recommended routinely before NCS. | |
| p.77 | III | C | Routine pre-operative ICA is not recommended in stable CCS patients undergoing low- and intermediate-risk NCS. | |
| p.77 | I | B | Smoking cessation .4 weeks before NCS is recommended to reduce post-operative complications and mortality. | |
| p.77 | I | B | Control of CV risk factors—including blood pressure, dyslipidaemia, and diabetes—is recommended before NCS. | |
| p.77 | I | B | Peri-operative continuation of beta-blockers is recommended in patients currently receiving this medication. | |
| p.77 | III | A | Routine initiation of beta-blocker peri-operatively is not recommended. | |
| p.77 | I | B | In patients already on statins, it is recommended to continue statins during the peri-operative period. | |
| p.77 | I | A | It is recommended to delay elective NCS until 6 months after elective PCI and 12 months after an ACS. | |
| p.77 | I | B | After elective PCI, it is recommended to delay time-sensitive NCS until a minimum of 1 month of DAPT treatment has been given. | |
| p.78 | I | B | In patients with a previous PCI, it is recommended to continue aspirin peri-operatively if the bleeding risk allows. | |
| p.78 | I | C | 48 h) post-surgery, according to interdisciplinary risk assessment. | |
| p.78 | I | C | When an urgent surgical intervention is required, it is recommended that NOAC therapy is immediately interrupted. | |
| p.78 | I | B | LMWH is recommended, as an alternative to UFH, for bridging in patients with MHVs and high surgical risk. | |
| p.78 | III | B | Bridging of OAC therapy is not recommended in patients with low/moderate thrombotic risk undergoing NCS. | |
| p.78 | III | C | Use of reduced-dose NOAC to attenuate the risk of post-operative bleeding is not recommended. | |
| p.78 | I | B | It is recommended to measure haemoglobin pre-operatively in patients scheduled for intermediate- to high-risk NCS. | |
| p.78 | I | A | It is recommended to treat anaemia in advance of NCS in order to reduce the need for RBC transfusion during NCS. | |
| p.78 | I | A | In patients undergoing surgery with expected blood loss of ≥500 mL, use of washed cell salvage is recommended. | |
| p.78 | I | A | It is recommended to use point-of-care diagnostics for guidance of blood component therapy, when available. | |
| p.78 | I | A | If PCI is indicated before NCS, the use of new-generation DES is recommended over BMS and balloon angioplasty. | |
| p.78 | III | B | Routine myocardial revascularization before low- and intermediate-risk NCS in patients with CCS is not recommended. | |
| p.78 | I | A | It is recommended that patients with HF undergoing NCS receive optimal medical treatment according to current ESC Guidelines. | |
| p.78 | I | C | In patients with HF undergoing NCS, it is recommended to regularly assess volume status and signs of organ perfusion. | |
| p.79 | I | C | In patients with ACHD, a consultation with an ACHD specialist is recommended before intermediate- or high-risk surgery. | |
| p.79 | I | C | In patients with SVT controlled by medication, it is recommended that AADs are continued during the peri-operative period. | |
| p.79 | I | B | In AF patients with acute or worsening haemodynamic instability undergoing NCS, emergency electrical cardioversion is recommended. | |
| p.79 | III | C | It is not recommended to initiate treatment of asymptomatic PVC during NCS. | |
| p.79 | I | C | It is recommended to continue chronic therapy for PAH in the peri-operative phase of NCS. | |
| p.79 | I | C | It is recommended that haemodynamic monitoring of patients with severe PAH continues for at least 24 h in the post-operative period. | |
| p.79 | III | C | It is not recommended to defer NCS in patients with stage 1 or 2 hypertension. | |
| p.79 | III | C | Routine referral for cardiac work-up, coronary angiography, or CPET prior to elective surgery for PAD or AAA is not recommended. | |
| p.80 | III | C | Pre-operative routine carotid artery imaging is not recommended in patients undergoing NCS. | |
| p.80 | I | B | It is recommended to avoid post-operative acute pain. | |
| p.80 | III | B | Non-aspirin NSAIDs are not recommended as first-line analgesics in patients with established or high risk of CVD. | |
| p.80 | I | B | Systematic PMI work-up is recommended to identify the underlying pathophysiology and define therapy. | |
| p.80 | I | C | Post-operative oral anticoagulation for PE is recommended to be administered for a period of at least 3 months. | |
| p.80 | I | A | In patients with a post-operative indication for OAC, NOAC is generally recommended over VKA. | |
| p.80 | III | B | Routine use of beta-blocker for the prevention of post-operative AF in patients undergoing NCS is not recommended. |